Provider Demographics
NPI:1356304380
Name:SOUTHARD, LARRY E (MA MFT)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:E
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:MA MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 E HIGHLAND AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404
Mailing Address - Country:US
Mailing Address - Phone:909-881-5250
Mailing Address - Fax:909-337-2724
Practice Address - Street 1:1255 E HIGHLAND AVE
Practice Address - Street 2:STE 105
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-881-5250
Practice Address - Fax:909-337-2724
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC18620106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
061147OtherHEALTHNET
065571OtherMANAGED HEALTH NETWORK
186380OtherMAGELLAN BEHAVIORAL HEALT
33B61DOtherRIVERSIDE CNTY BEHAVIORAL
5362524OtherAETNA BEHAVIORAL HEALTH P
019346OtherVMC BEHAVIORAL HEALTHCARE
56862099802OtherPACIFICARE BEHAVIORAL HEA
3112OtherCONCERN EAP
386213OtherVALUE OPTIONS
CA6270815OtherUS BEHAVIORAL HEALTH PLAN
208994OtherCIGNA BEHAVIORAL HEALTH
MFT18620OtherBLUE SHIELD OF CA