Provider Demographics
NPI:1881953131
Name:SUTHERLAND, MAXINE LEE (MED)
Entity type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:LEE
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 PAR DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1216
Mailing Address - Country:US
Mailing Address - Phone:561-704-9730
Mailing Address - Fax:
Practice Address - Street 1:1639 FORUM PL
Practice Address - Street 2:SUITE # 7
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2330
Practice Address - Country:US
Practice Address - Phone:561-712-8821
Practice Address - Fax:561-712-8070
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health