Basic Information
Provider Information | |||||||||
NPI: | 1902967896 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUNDERLAND | ||||||||
FirstName: | KIM | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FLOYD | ||||||||
OtherFirstName: | KIM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PH.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 673 MDG | ||||||||
Address2: | 5955 ZEAMER AVE | ||||||||
City: | JBER | ||||||||
State: | AK | ||||||||
PostalCode: | 99506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075802181 | ||||||||
FaxNumber: | 9075801776 | ||||||||
Practice Location | |||||||||
Address1: | 673 MDG | ||||||||
Address2: | 5955 ZEAMER AVE | ||||||||
City: | JBER | ||||||||
State: | AK | ||||||||
PostalCode: | 99506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9075802181 | ||||||||
FaxNumber: | 9075801776 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2006 | ||||||||
LastUpdateDate: | 03/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.