Provider Demographics
NPI:1477219061
Name:SUTHERLAND, STACI (LMSW)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:CLAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:180 N WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4335
Mailing Address - Country:US
Mailing Address - Phone:208-346-0688
Mailing Address - Fax:208-620-3027
Practice Address - Street 1:180 N WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4335
Practice Address - Country:US
Practice Address - Phone:208-346-0688
Practice Address - Fax:208-620-3027
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID393371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical