Provider Demographics
NPI:1275077364
Name:SOUTHERST, DANIELLE (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:
Last Name:SOUTHERST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-4331
Mailing Address - Country:US
Mailing Address - Phone:212-255-6690
Mailing Address - Fax:
Practice Address - Street 1:63 DOWNING ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-4331
Practice Address - Country:US
Practice Address - Phone:212-255-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012871-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor