Healthcare Provider Details

I. General information

NPI: 1588733638
Provider Name (Legal Business Name): COURTNEY SUTLIFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 W KILGORE AVE SUITE 6
YORKTOWN IN
47396-9290
US

IV. Provider business mailing address

7701 W KILGORE AVE SUITE 6
YORKTOWN IN
47396-9290
US

V. Phone/Fax

Practice location:
  • Phone: 765-744-2103
  • Fax:
Mailing address:
  • Phone: 765-744-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34006015A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: