Provider Demographics
NPI:1518702570
Name:MUMM, ELAINE
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:MUMM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 N DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-1323
Mailing Address - Country:US
Mailing Address - Phone:262-210-4500
Mailing Address - Fax:
Practice Address - Street 1:1075 N ELM ST STE 120
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-1205
Practice Address - Country:US
Practice Address - Phone:608-348-4060
Practice Address - Fax:608-348-4191
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134637-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker