Provider Demographics
NPI:1922381516
Name:CUMMINS, MIRA ELTON ROSE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:MIRA
Middle Name:ELTON ROSE
Last Name:CUMMINS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:MIRA
Other - Middle Name:ELTON ROSE
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:345 N. SMITH AVE, MAIL STOP 70-503
Mailing Address - Street 2:CHILDREN'S HOSPITALS AND CLINICS OF MINNESOTA
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:651-220-6479
Mailing Address - Fax:651-220-6393
Practice Address - Street 1:345 N. SMITH AVE, MAIL STOP 70-503
Practice Address - Street 2:CHILDREN'S HOSPITALS AND CLINICS OF MINNESOTA
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6479
Practice Address - Fax:651-220-6393
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN196841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical