Provider Demographics
NPI:1700414539
Name:MUDGE, IAN JAMES (LPC)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:JAMES
Last Name:MUDGE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 CUMBERLAND WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4211
Mailing Address - Country:US
Mailing Address - Phone:862-201-3495
Mailing Address - Fax:
Practice Address - Street 1:5320 CUMBERLAND WAY
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-4211
Practice Address - Country:US
Practice Address - Phone:862-201-3495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GALPC013731101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health