Provider Demographics
NPI:1689701187
Name:MUDD, MARY ANN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:MUDD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BELLEMEADE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5310
Mailing Address - Country:US
Mailing Address - Phone:502-429-6109
Mailing Address - Fax:
Practice Address - Street 1:9810 BLUEGRASS PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1906
Practice Address - Country:US
Practice Address - Phone:502-584-9781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0731235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist