Provider Demographics
NPI:1629563275
Name:SUTHERLAND, TIFFANY MARIE
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MARIE
Last Name:SUTHERLAND
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 1:10405 W 77TH ST APT 108
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1223
Mailing Address - Country:US
Mailing Address - Phone:773-406-4011
Mailing Address - Fax:
Practice Address - Street 1:9153 W 133RD ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-4333
Practice Address - Country:US
Practice Address - Phone:913-257-5185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-14-00309106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician