Provider Demographics
NPI:1477891281
Name:SOUTHALL, ANGELA M
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:SOUTHALL
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 1:3761 RUBY ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2715
Mailing Address - Country:US
Mailing Address - Phone:510-655-1681
Mailing Address - Fax:
Practice Address - Street 1:3761 RUBY ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2715
Practice Address - Country:US
Practice Address - Phone:510-655-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor