Provider Demographics
NPI:1932538477
Name:SUTTLES, SHAUN
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:SUTTLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2387 SOUTHSIDE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-9386
Mailing Address - Country:US
Mailing Address - Phone:704-740-7165
Mailing Address - Fax:
Practice Address - Street 1:635 COX RD STE B
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3441
Practice Address - Country:US
Practice Address - Phone:704-740-7165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10289101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health