Provider Demographics
NPI:1922658749
Name:SUTTLES, CARLA MARIE (MED, LPCC, LCADC)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
Last Name:SUTTLES
Suffix:
Gender:F
Credentials:MED, LPCC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 DOUBLE C ACRES LN
Mailing Address - Street 2:
Mailing Address - City:EUBANK
Mailing Address - State:KY
Mailing Address - Zip Code:42567-8663
Mailing Address - Country:US
Mailing Address - Phone:606-492-7196
Mailing Address - Fax:
Practice Address - Street 1:30 MEDPARK SQUARE DR STE 2
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-1709
Practice Address - Country:US
Practice Address - Phone:419-365-6846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
KY273150101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100810360Medicaid