Provider Demographics
NPI:1568641710
Name:SOUTHERLAND, ANGELA GAIL
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:GAIL
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 VASS RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8412
Mailing Address - Country:US
Mailing Address - Phone:901-670-6567
Mailing Address - Fax:910-904-2931
Practice Address - Street 1:635 VASS RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-8412
Practice Address - Country:US
Practice Address - Phone:901-670-6567
Practice Address - Fax:910-904-2931
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC38Medicaid
NC10Medicaid
NC30Medicaid
NC32Medicaid
NC17Medicaid
NC25Medicaid
NC33Medicaid
NC34Medicaid
NC347C00000Medicaid