Provider Demographics
NPI:1245237122
Name:MUDD, LARRY P (LCSW)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:P
Last Name:MUDD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVLLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3554
Mailing Address - Country:US
Mailing Address - Phone:812-282-1888
Mailing Address - Fax:812-218-9318
Practice Address - Street 1:510 SPRING ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVLLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3554
Practice Address - Country:US
Practice Address - Phone:812-282-1888
Practice Address - Fax:812-218-9318
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003409A1041C0700X
KY05661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8200068800Medicaid
IN800012255OtherMEDICARE RAILROAD
KY2748455000OtherPASSPORT ADVANTAGE
IN1608600Medicare ID - Type Unspecified
IN160780EEMedicare PIN
KY0676406Medicare ID - Type Unspecified
KY8200068800Medicaid