Provider Demographics
NPI:1003439027
Name:SOUTHARD, MATTHEW AARON (PHD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:AARON
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 W 147TH ST APT 5C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-3443
Mailing Address - Country:US
Mailing Address - Phone:716-908-3059
Mailing Address - Fax:
Practice Address - Street 1:287 W 147TH ST APT 5C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-3443
Practice Address - Country:US
Practice Address - Phone:716-908-3059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023407103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical