Provider Demographics
NPI:1508145897
Name:ROSA-SOUTHWORTH, TERI M (LPC)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:M
Last Name:ROSA-SOUTHWORTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 S VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9615
Mailing Address - Country:US
Mailing Address - Phone:989-551-1692
Mailing Address - Fax:
Practice Address - Street 1:1108 S VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9615
Practice Address - Country:US
Practice Address - Phone:989-551-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional