Provider Demographics
NPI:1376040188
Name:SUDDETH, TONIA ANTOINETTE
Entity Type:Individual
Prefix:
First Name:TONIA
Middle Name:ANTOINETTE
Last Name:SUDDETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 HARRISON STREET
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069
Mailing Address - Country:US
Mailing Address - Phone:601-809-9933
Mailing Address - Fax:
Practice Address - Street 1:600 MARINERS PLAZA DR STE 601
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448
Practice Address - Country:US
Practice Address - Phone:985-465-4250
Practice Address - Fax:866-497-7848
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X, 101Y00000X
LAPLC8539101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor