Provider Demographics
NPI:1093259111
Name:MUDD, MELISSA A (LAPC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MUDD
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 WHEELER RD
Mailing Address - Street 2:SUITE 365
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6549
Mailing Address - Country:US
Mailing Address - Phone:706-432-6866
Mailing Address - Fax:706-432-8775
Practice Address - Street 1:3633 WHEELER RD
Practice Address - Street 2:SUITE 365
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6549
Practice Address - Country:US
Practice Address - Phone:706-432-6866
Practice Address - Fax:706-432-8775
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005496101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAPC005496OtherSTATE LICENSE