Provider Demographics
NPI:1144289018
Name:MUDLOCK, LAURA (LAT, ATC, FD)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:MUDLOCK
Suffix:
Gender:F
Credentials:LAT, ATC, FD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 KENNEDY ST
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-1820
Mailing Address - Country:US
Mailing Address - Phone:570-814-5019
Mailing Address - Fax:
Practice Address - Street 1:20 MEMORIAL ST
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:PA
Practice Address - Zip Code:18643-2659
Practice Address - Country:US
Practice Address - Phone:570-655-2836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002370A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer