Healthcare Provider Details

I. General information

NPI: 1558265942
Provider Name (Legal Business Name): TAMRYN SUDDUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 FAIRVIEW DR APT 300
WILMINGTON NC
28412-0026
US

IV. Provider business mailing address

4605 FAIRVIEW DR APT 300
WILMINGTON NC
28412-0026
US

V. Phone/Fax

Practice location:
  • Phone: 224-390-2560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA23578
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: