Provider Demographics
NPI:1164810867
Name:SOUTHARD, MARY ELIZABETH (LMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
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 1:690A W MACCLENNY AVE
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2080
Mailing Address - Country:US
Mailing Address - Phone:904-400-0517
Mailing Address - Fax:
Practice Address - Street 1:690A W MACCLENNY AVE
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2080
Practice Address - Country:US
Practice Address - Phone:904-400-0517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-03
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health