Provider Demographics
NPI:1386004356
Name:MUMBLO, SHANNON K (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:K
Last Name:MUMBLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LONGFELLOW RD
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095-1842
Mailing Address - Country:US
Mailing Address - Phone:413-297-5552
Mailing Address - Fax:
Practice Address - Street 1:10 LONGFELLOW RD
Practice Address - Street 2:
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095-1842
Practice Address - Country:US
Practice Address - Phone:413-297-5552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1132561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical