Provider Demographics
NPI:1083047583
Name:SUTHERLAND, CHAD WAYNE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:WAYNE
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21702 LAWREY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-2039
Mailing Address - Country:US
Mailing Address - Phone:210-632-5200
Mailing Address - Fax:
Practice Address - Street 1:21702 LAWREY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-2039
Practice Address - Country:US
Practice Address - Phone:210-632-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT23012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
050502001OtherBOARD OF CERTIFICATION
TXAT2301OtherTEXAS DEPARTMENT OF STATE HEALTH SERVICES