Provider Demographics
NPI:1003242611
Name:SUTHERLAND, KIMBERLY ANNE (MED, CAC III)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MED, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2721
Mailing Address - Country:US
Mailing Address - Phone:720-324-0008
Mailing Address - Fax:
Practice Address - Street 1:1960 S SHERMAN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-4014
Practice Address - Country:US
Practice Address - Phone:720-324-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1707-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)