Provider Demographics
NPI:1629695291
Name:SOUTHALL, BERYL D (LPC)
Entity Type:Individual
Prefix:
First Name:BERYL
Middle Name:D
Last Name:SOUTHALL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3986 COUNTY ROAD 454
Mailing Address - Street 2:
Mailing Address - City:EL CAMPO
Mailing Address - State:TX
Mailing Address - Zip Code:77437-6640
Mailing Address - Country:US
Mailing Address - Phone:979-997-0527
Mailing Address - Fax:
Practice Address - Street 1:3986 COUNTY ROAD 454
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-6640
Practice Address - Country:US
Practice Address - Phone:979-997-0527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77657103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling