Provider Demographics
NPI:1295975902
Name:SUDDUTH, MARY HUNTER (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:HUNTER
Last Name:SUDDUTH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:VA
Mailing Address - Zip Code:22572-4280
Mailing Address - Country:US
Mailing Address - Phone:804-472-3706
Mailing Address - Fax:
Practice Address - Street 1:622 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:VA
Practice Address - Zip Code:22572-4280
Practice Address - Country:US
Practice Address - Phone:804-472-3706
Practice Address - Fax:866-639-3167
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040068471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA600669-942Medicaid
VAVAA100514Medicare UPIN