Provider Demographics
NPI:1720560782
Name:MUDDENAHALLI, SUMATHI V (MED, LPC)
Entity Type:Individual
Prefix:MISS
First Name:SUMATHI
Middle Name:V
Last Name:MUDDENAHALLI
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 SCHOLL RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1571
Mailing Address - Country:US
Mailing Address - Phone:419-756-1717
Mailing Address - Fax:419-756-5832
Practice Address - Street 1:741 SCHOLL RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1571
Practice Address - Country:US
Practice Address - Phone:419-756-1717
Practice Address - Fax:419-756-5832
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801193101YM0800X
OHC1801193101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health