Provider Demographics
NPI:1598744104
Name:MUMFORD, DEANNA L (PT)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:L
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1676 ROCKVIEW RD
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-8750
Mailing Address - Country:US
Mailing Address - Phone:815-284-2077
Mailing Address - Fax:815-284-2077
Practice Address - Street 1:1676 ROCKVIEW RD
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-8750
Practice Address - Country:US
Practice Address - Phone:815-284-2077
Practice Address - Fax:815-284-2077
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist