Healthcare Provider Details

I. General information

NPI: 1093259111
Provider Name (Legal Business Name): MELISSA A. MUDD LAPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WHEELER RD SUITE 365
AUGUSTA GA
30909-6549
US

IV. Provider business mailing address

3633 WHEELER RD SUITE 365
AUGUSTA GA
30909-6549
US

V. Phone/Fax

Practice location:
  • Phone: 706-432-6866
  • Fax: 706-432-8775
Mailing address:
  • Phone: 706-432-6866
  • Fax: 706-432-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC005496
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: