Provider Demographics
NPI:1619287612
Name:SOUTHARD, ALEXANDRA (LPCC-S)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:
Other - Last Name:KOONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2639
Mailing Address - Country:US
Mailing Address - Phone:614-722-2000
Mailing Address - Fax:
Practice Address - Street 1:444 BUTTERFLY GARDENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-3427
Practice Address - Country:US
Practice Address - Phone:614-355-8550
Practice Address - Fax:614-938-0594
Is Sole Proprietor?:No
Enumeration Date:2010-10-09
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900217101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid