Provider Demographics
NPI:1235868753
Name:SUTTON, ANNA BOULWARE (MED, LCMHCA)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:BOULWARE
Last Name:SUTTON
Suffix:
Gender:F
Credentials:MED, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 WILEY AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3240
Mailing Address - Country:US
Mailing Address - Phone:615-243-8723
Mailing Address - Fax:
Practice Address - Street 1:3901 BARRETT DR STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6523
Practice Address - Country:US
Practice Address - Phone:919-900-7552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health