Provider Demographics
NPI:1972962348
Name:SUTPHIN, SARA W (MED, LPP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:W
Last Name:SUTPHIN
Suffix:
Gender:F
Credentials:MED, LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-3411
Mailing Address - Country:US
Mailing Address - Phone:502-493-0412
Mailing Address - Fax:
Practice Address - Street 1:329 PLAZA AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3411
Practice Address - Country:US
Practice Address - Phone:502-493-0412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPSYPPR00223553103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling