Provider Demographics
NPI:1366755282
Name:MUDRY, LILY ANGELIKI (LCMHCS, LCAS, CCS)
Entity type:Individual
Prefix:
First Name:LILY
Middle Name:ANGELIKI
Last Name:MUDRY
Suffix:
Gender:F
Credentials:LCMHCS, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 EXECUTIVE CENTER DR. 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8859
Mailing Address - Country:US
Mailing Address - Phone:704-227-0605
Mailing Address - Fax:704-227-0690
Practice Address - Street 1:1942 E SEVENTH ST STE 220
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2418
Practice Address - Country:US
Practice Address - Phone:704-227-0610
Practice Address - Fax:704-227-0690
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2923101YA0400X
NCLCAS-1717101YA0400X
FLMH8494101YM0800X
NCCCS-564101YP2500X
NCS7638101YM0800X, 101YM0800X
NC7638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104577Medicaid