Provider Demographics
NPI:1497889794
Name:SOUTHER, JUDITH LORRAINE (OTR)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LORRAINE
Last Name:SOUTHER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:LORRAINE
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1511 BRANSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1437
Mailing Address - Country:US
Mailing Address - Phone:651-644-4086
Mailing Address - Fax:
Practice Address - Street 1:2705 ENLOE ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-8173
Practice Address - Country:US
Practice Address - Phone:715-386-2128
Practice Address - Fax:715-386-6119
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4141225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40872200Medicaid
7689529OtherAETNA
641671046996OtherPREFERRED ONE
98G59SOOtherBCBS MN
HP43837OtherHEALTH PARTNERS
6404305OtherMEDICA