Provider Demographics
NPI:1558813436
Name:SOUTHARD, STEPHEN (CMA, CCHT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:CMA, CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 ENTERPRISE RD
Mailing Address - Street 2:APT 3
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-1797
Mailing Address - Country:US
Mailing Address - Phone:813-505-9968
Mailing Address - Fax:
Practice Address - Street 1:2448 ENTERPRISE RD
Practice Address - Street 2:APT 3
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33763-1797
Practice Address - Country:US
Practice Address - Phone:813-505-9968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker