Provider Demographics
NPI:1306198262
Name:SOUTH, MIKLE (PHD)
Entity Type:Individual
Prefix:
First Name:MIKLE
Middle Name:
Last Name:SOUTH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 SHOUP CT
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4607
Mailing Address - Country:US
Mailing Address - Phone:404-727-8350
Mailing Address - Fax:
Practice Address - Street 1:1551 SHOUP CT
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4607
Practice Address - Country:US
Practice Address - Phone:404-727-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6841090-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical