Provider Demographics
NPI:1215112214
Name:KATHY ACUS-SOUDERS, PSY.D., LLC
Entity type:Organization
Organization Name:KATHY ACUS-SOUDERS, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ACUS-SOUDERS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:937-864-1940
Mailing Address - Street 1:2188 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6356
Mailing Address - Country:US
Mailing Address - Phone:937-864-1940
Mailing Address - Fax:937-864-1950
Practice Address - Street 1:2188 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6356
Practice Address - Country:US
Practice Address - Phone:937-864-1940
Practice Address - Fax:937-864-1950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5311103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHKA9358381Medicare PIN