Provider Demographics
NPI:1538489380
Name:MUDIE, PATRICE L (LCPC)
Entity Type:Individual
Prefix:MISS
First Name:PATRICE
Middle Name:L
Last Name:MUDIE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-9541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E BROADWAY ST STE 204
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4510
Practice Address - Country:US
Practice Address - Phone:406-546-7761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1153101YP2500X
MT76159103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1538489380Medicaid