Provider Demographics
NPI:1205356656
Name:ENTERTAINMENT, SOUTHERNBELLE
Entity Type:Individual
Prefix:
First Name:SOUTHERNBELLE
Middle Name:
Last Name:ENTERTAINMENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6483 SINCLAIR PL
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-2727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6483 SINCLAIR PL
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2727
Practice Address - Country:US
Practice Address - Phone:678-249-5718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist