Provider Demographics
NPI:1942425483
Name:SUTHERLIN, TERESA RENE (LCP)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:RENE
Last Name:SUTHERLIN
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5227
Mailing Address - Country:US
Mailing Address - Phone:620-275-1712
Mailing Address - Fax:
Practice Address - Street 1:531 CAMPUS VIEW ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-7904
Practice Address - Country:US
Practice Address - Phone:620-275-0644
Practice Address - Fax:620-272-0239
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCP 069103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy