Basic Information
Provider Information
NPI: 1003292921
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MUMFORD
FirstName: WENDY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LICSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 846 HARRIS AVE
Address2:  
City: WOONSOCKET
State: RI
PostalCode: 028951827
CountryCode: US
TelephoneNumber: 5083301545
FaxNumber:  
Practice Location
Address1: 189 PUTNAM PIKE
Address2:  
City: FOSTER
State: RI
PostalCode: 02825
CountryCode: US
TelephoneNumber: 5083301545
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/03/2015
LastUpdateDate: 08/03/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X118900MAN Behavioral Health & Social Service ProvidersSocial WorkerClinical
1041C0700XISW02561RIY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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