Provider Demographics
NPI:1720257124
Name:MUCKLOW, MARY BETH (AUD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:MUCKLOW
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2944 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-1409
Mailing Address - Country:US
Mailing Address - Phone:502-893-0159
Mailing Address - Fax:502-213-3884
Practice Address - Street 1:108 W DAISY LN
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4537
Practice Address - Country:US
Practice Address - Phone:502-893-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0520174400000X, 207Y00000X
IN23002305A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No174400000XOther Service ProvidersSpecialist
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200937310Medicaid
IN200937310Medicaid
IN265400QMedicare PIN