Provider Demographics
NPI:1053523167
Name:SUDDUTH, WILLIAM (M ED, MFT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:SUDDUTH
Suffix:
Gender:M
Credentials:M ED, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 33 BOX 2628
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89124-9271
Mailing Address - Country:US
Mailing Address - Phone:702-385-5331
Mailing Address - Fax:
Practice Address - Street 1:4285 N RANCHO DR STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3455
Practice Address - Country:US
Practice Address - Phone:702-385-5331
Practice Address - Fax:702-385-5678
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01012 MFT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist