Provider Demographics
NPI:1023298908
Name:SUTHERLAND, ALVIN C (LCSW)
Entity type:Individual
Prefix:
First Name:ALVIN
Middle Name:C
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 RESERVE HILL XING
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5188
Mailing Address - Country:US
Mailing Address - Phone:770-853-6372
Mailing Address - Fax:
Practice Address - Street 1:332 SHAWNEE INDIAN LN
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6531
Practice Address - Country:US
Practice Address - Phone:337-319-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004159101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional