Provider Demographics
NPI:1063389294
Name:SUTHERLAND, MONIQUE MAURICA
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MAURICA
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 HANDFIELD CT
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6329
Mailing Address - Country:US
Mailing Address - Phone:937-270-7554
Mailing Address - Fax:
Practice Address - Street 1:930 HANDFIELD CT
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6329
Practice Address - Country:US
Practice Address - Phone:937-270-7554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-22
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1500950104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty