Provider Demographics
NPI:1255651162
Name:SUTHERLAND, MARY MORAG (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY MORAG
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MAIN ST APT 305
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2465
Mailing Address - Country:US
Mailing Address - Phone:847-917-2951
Mailing Address - Fax:
Practice Address - Street 1:1400 RENAISSANCE DR STE 401
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1337
Practice Address - Country:US
Practice Address - Phone:847-318-8200
Practice Address - Fax:847-318-9170
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007653103TC0700X
IL071007653103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical