Provider Demographics
NPI:1487199832
Name:SOUTHARD, VERONICA (PT)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 BAYVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-1608
Mailing Address - Country:US
Mailing Address - Phone:516-628-2154
Mailing Address - Fax:516-686-7699
Practice Address - Street 1:186 BAYVILLE AVE
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11709-1608
Practice Address - Country:US
Practice Address - Phone:516-686-7671
Practice Address - Fax:516-686-7671
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY64422251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics