Provider Demographics
NPI:1508379934
Name:MUDREY, MARSHA R (LPC)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:R
Last Name:MUDREY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 RIVERSTONE BOULEVARD
Mailing Address - Street 2:SUITE 273
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5250
Mailing Address - Country:US
Mailing Address - Phone:762-441-1263
Mailing Address - Fax:
Practice Address - Street 1:2205 RIVERSTONE BOULEVARD
Practice Address - Street 2:SUITE 273
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5250
Practice Address - Country:US
Practice Address - Phone:762-441-1263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty