Provider Demographics
NPI:1265646251
Name:SOUTHERLAND, MARTIE L (MHPP)
Entity Type:Individual
Prefix:
First Name:MARTIE
Middle Name:L
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:MARTIE
Other - Middle Name:L
Other - Last Name:MCCAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4253 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4593
Mailing Address - Country:US
Mailing Address - Phone:479-521-5731
Mailing Address - Fax:479-521-4926
Practice Address - Street 1:10301 MAYO DR
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923-1660
Practice Address - Country:US
Practice Address - Phone:479-494-5740
Practice Address - Fax:479-484-8142
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator