Provider Demographics
NPI:1346591757
Name:SUTHERLAND, CONCHITA DOLORES (LMT)
Entity type:Individual
Prefix:MS
First Name:CONCHITA
Middle Name:DOLORES
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CHI
Other - Middle Name:
Other - Last Name:SUTHERLAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:ASH FORK
Mailing Address - State:AZ
Mailing Address - Zip Code:86320-0052
Mailing Address - Country:US
Mailing Address - Phone:520-924-0252
Mailing Address - Fax:
Practice Address - Street 1:607 W GURLEY ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3619
Practice Address - Country:US
Practice Address - Phone:928-227-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-07772225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist