Healthcare Provider Details

I. General information

NPI: 1063329787
Provider Name (Legal Business Name): AMELIA MUDD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 ROSEMONT DR STE 115
FORT MILL SC
29707-7765
US

IV. Provider business mailing address

12919 BALLANTYNE CORPORATE PL APT G
CHARLOTTE NC
28277-0430
US

V. Phone/Fax

Practice location:
  • Phone: 803-281-0185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number9391
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: