Provider Demographics
NPI:1083228084
Name:SUTHERLAND, KATHLEEN (MSCP, AMFT, APCC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MSCP, AMFT, APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16738 LAKESHORE DR # H208
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4930
Mailing Address - Country:US
Mailing Address - Phone:714-794-2040
Mailing Address - Fax:
Practice Address - Street 1:4849 GREENVILLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-4187
Practice Address - Country:US
Practice Address - Phone:972-885-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15688101YM0800X
CA144755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health