Provider Demographics
NPI:1033763644
Name:MUDD, LUKE ANTHONY (PSYD)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:ANTHONY
Last Name:MUDD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 CROSS ARM DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2762
Mailing Address - Country:US
Mailing Address - Phone:312-659-8896
Mailing Address - Fax:
Practice Address - Street 1:325 N WELLS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-7024
Practice Address - Country:US
Practice Address - Phone:312-659-8896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008485103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist