MEDICARE: MARY ALISA SUTHERLAND LPC

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	101YM0800X	Mental Health Counselor	C-6446	OH

General Provider Information

NPI Number	:	1639179302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ALISA SUTHERLAND LPC

Provider Business Mailing Address
First Line	:	3949 S 6TH ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-4746
Country	:	US
Telephone Number	:	800-552-6290
Fax Number	:	541-880-0560

Provider Business Practice Location Address
First Line	:	3949 S 6TH ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-4746
Country	:	US
Telephone Number	:	800-552-6290
Fax Number	:	541-880-0560

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/08/2007

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