Provider Demographics
NPI:1093002990
Name:SUTHERLAND, STACY MAE (MED)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MAE
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 FOWLER DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76209-1919
Mailing Address - Country:US
Mailing Address - Phone:574-870-0332
Mailing Address - Fax:
Practice Address - Street 1:1403 GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76209-2206
Practice Address - Country:US
Practice Address - Phone:940-765-6487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66834101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional