Provider Demographics
NPI:1003028069
Name:SOUTHARD, LAURA A (DPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 PERIMETER PARK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:984-215-4110
Mailing Address - Fax:
Practice Address - Street 1:222 ASHVILLE AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6130
Practice Address - Country:US
Practice Address - Phone:919-863-5924
Practice Address - Fax:919-863-5923
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00010496225100000X
MEPT3775225100000X
NC153962251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8482622Medicaid
WA8866202Medicare PIN