Provider Demographics
NPI:1043818271
Name:SOUTHARD, SAMANTHA TAYLOR (LMHC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TAYLOR
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8921 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-5850
Mailing Address - Country:US
Mailing Address - Phone:646-341-3158
Mailing Address - Fax:
Practice Address - Street 1:2285 VICTORY BLVD STE 1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6631
Practice Address - Country:US
Practice Address - Phone:646-389-3797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-10
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty