Provider Demographics
NPI:1376139667
Name:MUMM, REBECCA NELSON (LMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:NELSON
Last Name:MUMM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1889
Mailing Address - Country:US
Mailing Address - Phone:208-351-3086
Mailing Address - Fax:
Practice Address - Street 1:343 E 4TH N STE 128
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6004
Practice Address - Country:US
Practice Address - Phone:208-351-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-40249104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker