Provider Demographics
NPI:1558981076
Name:SOUTHERN, THOMAS LAURIE JR (SLPD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LAURIE
Last Name:SOUTHERN
Suffix:JR
Gender:M
Credentials:SLPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53359 CHAMPLAIN ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-3739
Mailing Address - Country:US
Mailing Address - Phone:586-859-9607
Mailing Address - Fax:
Practice Address - Street 1:53359 CHAMPLAIN ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-3739
Practice Address - Country:US
Practice Address - Phone:586-859-9607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001203235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist