Provider Demographics
NPI:1184676702
Name:SOUTHERN, LISA M (LMLP, LCP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:LMLP, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 E KANSAS PLZ
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846-5870
Mailing Address - Country:US
Mailing Address - Phone:620-275-0625
Mailing Address - Fax:620-275-7908
Practice Address - Street 1:1145 E KANSAS PLZ
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5870
Practice Address - Country:US
Practice Address - Phone:620-275-0625
Practice Address - Fax:620-275-7908
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMLP 0495103TB0200X
KSLCP 128103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist