Healthcare Provider Details

I. General information

NPI: 1518702570
Provider Name (Legal Business Name): ELAINE MUMM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 06/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 N ELM ST STE 120
PLATTEVILLE WI
53818-1205
US

IV. Provider business mailing address

318 N DOUGLAS ST
DODGEVILLE WI
53533-1323
US

V. Phone/Fax

Practice location:
  • Phone: 608-348-4060
  • Fax: 608-348-4191
Mailing address:
  • Phone: 262-210-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number134637-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: