Basic Information
Provider Information | |||||||||
NPI: | 1982762357 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOUGLASS-EVERHARD | ||||||||
FirstName: | SUZYN | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DOUGLASS | ||||||||
OtherFirstName: | SUZYN | ||||||||
OtherMiddleName: | MARY | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC, LPCC | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 495 ERLANGER RD | ||||||||
Address2: | SUITE 204 | ||||||||
City: | ERLANGER | ||||||||
State: | KY | ||||||||
PostalCode: | 410181468 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8593426444 | ||||||||
FaxNumber: | 8593420999 | ||||||||
Practice Location | |||||||||
Address1: | 650 JOEL DR | ||||||||
Address2: |   | ||||||||
City: | FORT CAMPBELL | ||||||||
State: | KY | ||||||||
PostalCode: | 422235318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2707988400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2006 | ||||||||
LastUpdateDate: | 09/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | KY-0854 | KY | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 64067 | TX | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 172576 | KY | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 1982762357 | 01 | KY | NPI | OTHER |