Provider Demographics
NPI:1043407190
Name:SOUTHERN, DOUGLAS STEPHEN (PHD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:STEPHEN
Last Name:SOUTHERN
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:PO BOX 3391
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-3391
Mailing Address - Country:US
Mailing Address - Phone:575-624-8889
Mailing Address - Fax:
Practice Address - Street 1:104 E LINDA VISTA BLVD STE B
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6667
Practice Address - Country:US
Practice Address - Phone:575-624-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0128981101YP2500X
NM1353103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10180087Medicaid