Provider Demographics
NPI:1720368012
Name:SUTHERLAND, WILLIAM L (MED)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:L
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 W BETHEL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9696
Mailing Address - Country:US
Mailing Address - Phone:573-424-3316
Mailing Address - Fax:
Practice Address - Street 1:601 W NIFONG BLVD STE 5A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6804
Practice Address - Country:US
Practice Address - Phone:573-424-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011026062101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional