Provider Demographics
NPI:1801374897
Name:MUDD, THOMAS LEO (PT, DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEO
Last Name:MUDD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 BRIAR CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-8941
Mailing Address - Country:US
Mailing Address - Phone:502-460-3868
Mailing Address - Fax:
Practice Address - Street 1:875 PENNSYLVANIA AVE STE A
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2529
Practice Address - Country:US
Practice Address - Phone:502-349-6961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HVNAN0707355OtherANTHEM