Healthcare Provider Details

I. General information

NPI: 1003209826
Provider Name (Legal Business Name): MARIANA GUMM ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 MAIN ST
LIVINGSTON CA
95334-1257
US

IV. Provider business mailing address

1140 MAIN ST
LIVINGSTON CA
95334-1257
US

V. Phone/Fax

Practice location:
  • Phone: 209-394-7913
  • Fax: 209-394-3660
Mailing address:
  • Phone: 209-394-7913
  • Fax: 209-394-3660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number61321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: