Provider Demographics
NPI:1639339229
Name:SUTTON, MICA DEANN (LCSM)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:DEANN
Last Name:SUTTON
Suffix:
Gender:F
Credentials:LCSM
Other - Prefix:
Other - First Name:MICA
Other - Middle Name:DEANN
Other - Last Name:KIANETSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:448 WYLIE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5405
Mailing Address - Country:US
Mailing Address - Phone:888-924-3786
Mailing Address - Fax:309-451-7763
Practice Address - Street 1:10640 BUSINESS 21
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-5039
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5137-M104100000X
MO20200175071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker