Provider Demographics
NPI:1073660650
Name:SUDA, MARY ANN (MA, LMHP, CPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:SUDA
Suffix:
Gender:F
Credentials:MA, LMHP, CPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W 2ND ST
Mailing Address - Street 2:POB 744
Mailing Address - City:MCCOOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-3607
Mailing Address - Country:US
Mailing Address - Phone:308-345-4676
Mailing Address - Fax:308-345-4676
Practice Address - Street 1:207 W 2ND ST
Practice Address - Street 2:POB 744
Practice Address - City:MCCOOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3607
Practice Address - Country:US
Practice Address - Phone:308-345-4676
Practice Address - Fax:308-345-4676
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1983101YM0800X
NE1138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE84722OtherBC-BS ID NUMBER
NE47084540826Medicaid