Provider Demographics
NPI:1588020788
Name:SOUTHERLAN, DENA (LCSW)
Entity Type:Individual
Prefix:
First Name:DENA
Middle Name:
Last Name:SOUTHERLAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7612
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-7612
Mailing Address - Country:US
Mailing Address - Phone:970-445-2700
Mailing Address - Fax:970-445-2700
Practice Address - Street 1:1143 CAPITOL STREET UNIT 206C
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631
Practice Address - Country:US
Practice Address - Phone:970-445-2700
Practice Address - Fax:970-445-2700
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099242041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical