Provider Demographics
NPI:1730363813
Name:MUMFORD, SUSAN C (MSW, LISW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:C
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 S EDWIN C. MOSES BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45408
Mailing Address - Country:US
Mailing Address - Phone:937-223-8840
Mailing Address - Fax:937-223-0758
Practice Address - Street 1:627 S. EDWIN C. MOSES BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408
Practice Address - Country:US
Practice Address - Phone:937-223-8840
Practice Address - Fax:937-223-0758
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.00086411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical