Provider Demographics
NPI:1598831463
Name:SUNDERLAND, LILEO T (MFT)
Entity Type:Individual
Prefix:
First Name:LILEO
Middle Name:T
Last Name:SUNDERLAND
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2275
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-2275
Mailing Address - Country:US
Mailing Address - Phone:775-783-1136
Mailing Address - Fax:775-783-1136
Practice Address - Street 1:1191 HIGH SCHOOL ST # A
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5376
Practice Address - Country:US
Practice Address - Phone:775-783-1136
Practice Address - Fax:775-783-1136
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0673106H00000X
CA20395106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20395OtherMFT LICENSE
NV0673OtherMFT LICENSE