Provider Demographics
NPI:1093006637
Name:SUTHERLAND, KIMBERLY ANN (LCPC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W BARTLETT AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-7880
Mailing Address - Country:US
Mailing Address - Phone:630-837-5303
Mailing Address - Fax:630-837-5305
Practice Address - Street 1:106 W BARTLETT AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-7880
Practice Address - Country:US
Practice Address - Phone:630-837-5303
Practice Address - Fax:630-837-5305
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-01
Last Update Date:2011-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007152101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health