Healthcare Provider Details

I. General information

NPI: 1992462105
Provider Name (Legal Business Name): SUSAN MARIE KERR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 12/18/2021
Certification Date: 12/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 S 16TH ST
LEAVENWORTH KS
66048-2915
US

IV. Provider business mailing address

1412 S 16TH ST
LEAVENWORTH KS
66048-2915
US

V. Phone/Fax

Practice location:
  • Phone: 913-388-9143
  • Fax:
Mailing address:
  • Phone: 913-306-4299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number03939
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: