Provider Demographics
NPI:1134778046
Name:MUMFORD, SERINA (LISW)
Entity type:Individual
Prefix:
First Name:SERINA
Middle Name:
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4995 BRADENTON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3551
Mailing Address - Country:US
Mailing Address - Phone:614-580-6917
Mailing Address - Fax:
Practice Address - Street 1:4995 BRADENTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3551
Practice Address - Country:US
Practice Address - Phone:614-580-6917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2106550104100000X
OHI.24055571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty