Provider Demographics
NPI:1114100658
Name:SUDERMAN, CONNIE FAYE (LSCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:FAYE
Last Name:SUDERMAN
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 N TYLER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4917
Mailing Address - Country:US
Mailing Address - Phone:316-722-4884
Mailing Address - Fax:316-722-4893
Practice Address - Street 1:1660 N TYLER RD
Practice Address - Street 2:SUITE A
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4917
Practice Address - Country:US
Practice Address - Phone:316-722-4884
Practice Address - Fax:316-722-4893
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMSW-25601041C0700X
KSLSCSW - 40161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical