Provider Demographics
NPI:1508998014
Name:SOUTHARD, SHELIA FONSECA (MED, CCC,SLP)
Entity Type:Individual
Prefix:
First Name:SHELIA
Middle Name:FONSECA
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:MED, CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ZEE ANN DR
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-3130
Mailing Address - Country:US
Mailing Address - Phone:985-785-2952
Mailing Address - Fax:
Practice Address - Street 1:25 ZEE ANN DR
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-3130
Practice Address - Country:US
Practice Address - Phone:985-785-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2859235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1310875Medicaid