Provider Demographics
NPI:1164012258
Name:MUDD, MARY CATHERINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:MUDD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 E JOHN ROWAN BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-3265
Mailing Address - Country:US
Mailing Address - Phone:502-331-4778
Mailing Address - Fax:
Practice Address - Street 1:3615 E JOHN ROWAN BLVD STE 201
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-3265
Practice Address - Country:US
Practice Address - Phone:502-331-4778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0071512251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic