Provider Demographics
NPI:1558389908
Name:SOUTHARD, PEGGY A (LCMFT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:A
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:A
Other - Last Name:SELLNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:PO BOX 677
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-0677
Mailing Address - Country:US
Mailing Address - Phone:785-242-3780
Mailing Address - Fax:785-242-6397
Practice Address - Street 1:2537 EISENHOWER RD
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-9482
Practice Address - Country:US
Practice Address - Phone:785-242-3780
Practice Address - Fax:785-242-6397
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCMFT 673106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200431710AMedicaid