Provider Demographics
NPI:1730291246
Name:MUMFORD, MARY SHACKELFORD (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SHACKELFORD
Last Name:MUMFORD
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 1:17 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4315
Mailing Address - Country:US
Mailing Address - Phone:781-686-9121
Mailing Address - Fax:
Practice Address - Street 1:1354 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5109
Practice Address - Country:US
Practice Address - Phone:617-471-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10216981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMU PO6400OtherMEDICARE
MAMU PO6400Medicare ID - Type Unspecified