Provider Demographics
NPI:1558086603
Name:SUTHERLAND, CLINTON
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 CYPRESS TRCE
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-4956
Mailing Address - Country:US
Mailing Address - Phone:561-298-9781
Mailing Address - Fax:
Practice Address - Street 1:6566 NEWPORT LAKE CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-3001
Practice Address - Country:US
Practice Address - Phone:561-298-9781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-224227103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst