Provider Demographics
NPI:1396833273
Name:MUMBULO, ROSEMARY ELLEN (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:ROSEMARY
Middle Name:ELLEN
Last Name:MUMBULO
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TIOGA BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-4150
Mailing Address - Country:US
Mailing Address - Phone:607-625-4355
Mailing Address - Fax:607-625-4438
Practice Address - Street 1:3 TIOGA BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-4150
Practice Address - Country:US
Practice Address - Phone:607-625-4355
Practice Address - Fax:607-625-4438
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR058569-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0673Medicare ID - Type Unspecified