Provider Demographics
NPI:1306198411
Name:SUTTON, ALICIA (CPS)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:SUTTON
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 CHEZ VANT CT
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-3542
Mailing Address - Country:US
Mailing Address - Phone:314-518-1188
Mailing Address - Fax:
Practice Address - Street 1:248 CHEZ VANT CT
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-3542
Practice Address - Country:US
Practice Address - Phone:314-518-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11674175T00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1306198411Medicaid