Healthcare Provider Details

I. General information

NPI: 1629213673
Provider Name (Legal Business Name): KENNETH SUTHERLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2008
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SPRING ST
JEFFERSONVILLE IN
47130-3452
US

IV. Provider business mailing address

8716 LONGBOROUGH WAY
LOUISVILLE KY
40299-1133
US

V. Phone/Fax

Practice location:
  • Phone: 812-280-2080
  • Fax:
Mailing address:
  • Phone: 502-384-9337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: