Healthcare Provider Details

I. General information

NPI: 1912133323
Provider Name (Legal Business Name): IDA MAE SUTTMOLLER MA LCSW CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 WEST JASPER
VERSAILLES MO
65084
US

IV. Provider business mailing address

108 WEST JASPER
VERSALLIES MO
65084
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-6833
  • Fax: 573-378-6823
Mailing address:
  • Phone: 573-378-6833
  • Fax: 573-378-6823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number868
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number003970
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: