Provider Demographics
NPI:1578847612
Name:SOUTHERN, JOANN (2705001197)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:2705001197
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 28TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1622
Mailing Address - Country:US
Mailing Address - Phone:616-241-1216
Mailing Address - Fax:
Practice Address - Street 1:2893 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1622
Practice Address - Country:US
Practice Address - Phone:616-241-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2705001197225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist