Provider Demographics
NPI:1285028332
Name:SOUTHAM, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SOUTHAM
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 1:27 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CLEONA
Mailing Address - State:PA
Mailing Address - Zip Code:17042-2341
Mailing Address - Country:US
Mailing Address - Phone:717-838-2600
Mailing Address - Fax:
Practice Address - Street 1:2855 HORSESHOE PIKE
Practice Address - Street 2:
Practice Address - City:CAMPBELLTOWN
Practice Address - State:PA
Practice Address - Zip Code:17010
Practice Address - Country:US
Practice Address - Phone:717-838-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG002743225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist