Provider Demographics
NPI:1912133323
Name:SUTTMOLLER, IDA MAE (MA LCSW CASAC)
Entity Type:Individual
Prefix:MRS
First Name:IDA
Middle Name:MAE
Last Name:SUTTMOLLER
Suffix:
Gender:F
Credentials:MA LCSW CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:108 WEST JASPER
Mailing Address - Street 2:
Mailing Address - City:VERSALLIES
Mailing Address - State:MO
Mailing Address - Zip Code:65084
Mailing Address - Country:US
Mailing Address - Phone:573-378-6833
Mailing Address - Fax:573-378-6823
Practice Address - Street 1:108 WEST JASPER
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084
Practice Address - Country:US
Practice Address - Phone:573-378-6833
Practice Address - Fax:573-378-6823
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO868101YA0400X
MO0039701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)