Provider Demographics
NPI:1538290523
Name:MUMFORD, MARK CARPENTER (MA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:CARPENTER
Last Name:MUMFORD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:COUNSELING SERVICE OF ADDISON COUNTY,INC.
Mailing Address - Street 2:89 MAIN STREET
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753
Mailing Address - Country:US
Mailing Address - Phone:802-388-6741
Mailing Address - Fax:802-388-8183
Practice Address - Street 1:COUNSELING SERVICE OF ADDISON COUNTY,INC.
Practice Address - Street 2:89 MAIN STREET
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753
Practice Address - Country:US
Practice Address - Phone:802-388-6741
Practice Address - Fax:802-388-8183
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT297103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent