Provider Demographics
NPI:1235313719
Name:SOUTHWORTH, SUSAN MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S PLATTE CLAY WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-8797
Mailing Address - Country:US
Mailing Address - Phone:816-914-5322
Mailing Address - Fax:816-628-5452
Practice Address - Street 1:310 S PLATTE CLAY WAY
Practice Address - Street 2:SUITE C
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-8797
Practice Address - Country:US
Practice Address - Phone:816-914-5322
Practice Address - Fax:816-628-5452
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01928103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist