Provider Demographics
NPI:1215189030
Name:SUTHERLAND, PETER M (LAC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 664
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521-9797
Mailing Address - Country:US
Mailing Address - Phone:406-395-4818
Mailing Address - Fax:406-395-4861
Practice Address - Street 1:RR 1 BOX 664
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-9797
Practice Address - Country:US
Practice Address - Phone:406-395-4818
Practice Address - Fax:406-395-4861
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1271101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)