Provider Demographics
NPI:1629369384
Name:SOUTHERN, HEIDI L (MA, LPC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:L
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 COLOMBO AVE APT 5201
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-5310
Mailing Address - Country:US
Mailing Address - Phone:469-955-6579
Mailing Address - Fax:
Practice Address - Street 1:1201 COLOMBO AVE APT 5201
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-5310
Practice Address - Country:US
Practice Address - Phone:469-955-6579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65482101Y00000X, 101YM0800X, 103T00000X, 103TC1900X, 171M00000X, 101YP2500X
AZ19369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No171M00000XOther Service ProvidersCase Manager/Care Coordinator