Provider Demographics
NPI:1174523070
Name:ACUS-SOUDERS, KATHY LYNN (PSYD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:LYNN
Last Name:ACUS-SOUDERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 WHIPPOORWILL CT
Mailing Address - Street 2:
Mailing Address - City:ENON
Mailing Address - State:OH
Mailing Address - Zip Code:45323-9792
Mailing Address - Country:US
Mailing Address - Phone:937-864-1940
Mailing Address - Fax:937-864-1950
Practice Address - Street 1:2188 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6356
Practice Address - Country:US
Practice Address - Phone:937-864-7122
Practice Address - Fax:937-864-1950
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5311103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHKA9358381Medicare PIN