Provider Demographics
NPI:1578148409
Name:MUDD, ELIZABETH (DPT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MUDD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 HORAN LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:40069-8904
Mailing Address - Country:US
Mailing Address - Phone:859-940-0411
Mailing Address - Fax:
Practice Address - Street 1:727 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1838
Practice Address - Country:US
Practice Address - Phone:270-321-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY005917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty