Provider Demographics
NPI:1740332535
Name:MUMBLO, KEITH (MSW)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:MUMBLO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 DERRYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1322
Mailing Address - Country:US
Mailing Address - Phone:413-796-4943
Mailing Address - Fax:
Practice Address - Street 1:622 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-4104
Practice Address - Country:US
Practice Address - Phone:413-439-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1122621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical