Provider Demographics
NPI:1033995063
Name:HOWARD, SOUTHIDA
Entity Type:Individual
Prefix:
First Name:SOUTHIDA
Middle Name:
Last Name:HOWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOUTHIDA
Other - Middle Name:
Other - Last Name:SOURATHA-HOWARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:PO BOX 11072
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90295-7072
Mailing Address - Country:US
Mailing Address - Phone:310-849-7799
Mailing Address - Fax:
Practice Address - Street 1:2905 STANFORD AVE
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5524
Practice Address - Country:US
Practice Address - Phone:310-849-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55758225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist