Healthcare Provider Details

I. General information

NPI: 1619140563
Provider Name (Legal Business Name): ASHLEY MUDD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 04/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 TEKE BURTON DR
MITCHELL IN
47446-7360
US

IV. Provider business mailing address

1226 STATE ROAD 550
LOOGOOTEE IN
47553-4754
US

V. Phone/Fax

Practice location:
  • Phone: 812-849-2221
  • Fax:
Mailing address:
  • Phone: 812-849-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06003405A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: