Healthcare Provider Details

I. General information

NPI: 1063531440
Provider Name (Legal Business Name): KATHLEEN SUDA RN-PLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2848 ELK PEAK CT
SAINT LOUIS MO
63129-5706
US

IV. Provider business mailing address

2848 ELK PEAK CT
SAINT LOUIS MO
63129-5706
US

V. Phone/Fax

Practice location:
  • Phone: 314-846-6814
  • Fax: 314-846-6814
Mailing address:
  • Phone: 314-846-6814
  • Fax: 314-846-6814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number062430
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2007025784
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: