MEDICARE: CLINTON SUTHERLAND

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	103K00000X	Behavior Analyst	RBT-22-224227	FL

General Provider Information

NPI Number	:	1558086603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINTON SUTHERLAND

Provider Business Mailing Address
First Line	:	220 CYPRESS TRCE
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-4956
Country	:	US
Telephone Number	:	561-298-9781
Fax Number	:

Provider Business Practice Location Address
First Line	:	6566 NEWPORT LAKE CIR
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33496-3001
Country	:	US
Telephone Number	:	561-298-9781
Fax Number	:

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

Provider Enumeration Date	:	10/10/2022
Last Update Date	:	12/20/2022

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Directions to “ CLINTON SUTHERLAND ” Practice Location

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