Healthcare Provider Details

I. General information

NPI: 1639339229
Provider Name (Legal Business Name): MICA DEANN SUTTON LCSM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICA DEANN KIANETSKI LCSW

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10640 BUSINESS 21
HILLSBORO MO
63050-5039
US

IV. Provider business mailing address

448 WYLIE DR
NORMAL IL
61761-5405
US

V. Phone/Fax

Practice location:
  • Phone: 618-877-4420
  • Fax:
Mailing address:
  • Phone: 888-924-3786
  • Fax: 309-451-7763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5137-M
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2020017507
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: