Provider Demographics
NPI:1154582260
Name:SUTHERLAND, GAYLE MOSS
Entity type:Individual
Prefix:MS
First Name:GAYLE
Middle Name:MOSS
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 1:161 WESTHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8617
Mailing Address - Country:US
Mailing Address - Phone:270-534-8540
Mailing Address - Fax:270-534-1688
Practice Address - Street 1:161 WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-8617
Practice Address - Country:US
Practice Address - Phone:270-534-8540
Practice Address - Fax:270-534-1688
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1272104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker