MEDICARE: KATHLEEN SUDA RN-PLPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse	062430	MO
2	101YP2500X	Professional Counselor	2007025784	MO

General Provider Information

NPI Number	:	1063531440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN SUDA RN-PLPC

Provider Business Mailing Address
First Line	:	2848 ELK PEAK CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-5706
Country	:	US
Telephone Number	:	314-846-6814
Fax Number	:	314-846-6814

Provider Business Practice Location Address
First Line	:	2848 ELK PEAK CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-5706
Country	:	US
Telephone Number	:	314-846-6814
Fax Number	:	314-846-6814

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	05/05/2008

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