Provider Demographics
NPI:1558126201
Name:MUKORO, MUDDY
Entity Type:Individual
Prefix:MR
First Name:MUDDY
Middle Name:
Last Name:MUKORO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5560 TWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-3792
Mailing Address - Country:US
Mailing Address - Phone:404-207-8202
Mailing Address - Fax:
Practice Address - Street 1:2459 ROOSEVELT HWY STE B17
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30337-5592
Practice Address - Country:US
Practice Address - Phone:470-506-5035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral