Provider Demographics
NPI:1235562737
Name:SOUTHWORTH, JANIS MARIE (MA PC-TC)
Entity Type:Individual
Prefix:MS
First Name:JANIS
Middle Name:MARIE
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:MA PC-TC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W BROADWAY AVE
Mailing Address - Street 2:P O BOX 297
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1757
Mailing Address - Country:US
Mailing Address - Phone:715-748-4535
Mailing Address - Fax:715-748-0627
Practice Address - Street 1:136 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1757
Practice Address - Country:US
Practice Address - Phone:715-748-4535
Practice Address - Fax:715-748-0627
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1773-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional