Healthcare Provider Details

I. General information

NPI: 1053523167
Provider Name (Legal Business Name): WILLIAM SUDDUTH M ED., MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 N RANCHO DR STE 130
LAS VEGAS NV
89130-3455
US

IV. Provider business mailing address

HC 33 BOX 2628
LAS VEGAS NV
89124-9271
US

V. Phone/Fax

Practice location:
  • Phone: 702-385-5331
  • Fax: 702-385-5678
Mailing address:
  • Phone: 702-385-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number01012 MFT
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: