Provider Demographics
NPI:1497280598
Name:SOUTHICHACK, SOMSOUK (RN, PMHNP)
Entity Type:Individual
Prefix:
First Name:SOMSOUK
Middle Name:
Last Name:SOUTHICHACK
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-8450
Mailing Address - Fax:
Practice Address - Street 1:3200 W EULESS BLVD
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-6253
Practice Address - Country:US
Practice Address - Phone:817-702-3100
Practice Address - Fax:817-920-6271
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132679363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health