Provider Demographics
NPI:1811198799
Name:UMENTUM, IDA MARY (MSW)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:MARY
Last Name:UMENTUM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:MARY
Other - Last Name:SCHANEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:3122 SAVANNA WAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5043
Mailing Address - Country:US
Mailing Address - Phone:920-321-0387
Mailing Address - Fax:
Practice Address - Street 1:141 SIEGLER ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2635
Practice Address - Country:US
Practice Address - Phone:920-497-3126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI888-122104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker