Healthcare Provider Details

I. General information

NPI: 1124375910
Provider Name (Legal Business Name): DESIREE ALANA SUTHERLAND PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

4424 ELLENWOOD AVE
SAINT LOUIS MO
63116-1522
US

V. Phone/Fax

Practice location:
  • Phone: 573-424-3735
  • Fax:
Mailing address:
  • Phone: 573-424-3735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2012001786
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: