MEDICARE: SUSAN KAY STUTENROTH LCSW

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	1041C0700X	Clinical Social Worker	LCSW-11516	AZ

General Provider Information

NPI Number	:	1730377938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN KAY STUTENROTH LCSW

Provider Business Mailing Address
First Line	:	220 S 12TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-3101
Country	:	US
Telephone Number	:	602-372-2104
Fax Number	:	601-372-2164

Provider Business Practice Location Address
First Line	:	220 S 12TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85007-3101
Country	:	US
Telephone Number	:	602-372-2104
Fax Number	:	601-372-2164

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

Provider Enumeration Date	:	10/12/2007
Last Update Date	:	10/12/2007

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