Provider Demographics
NPI:1659139327
Name:SOUTHERS, WESLEY ALLEN (CDCA)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:ALLEN
Last Name:SOUTHERS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 FIVE OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-5218
Mailing Address - Country:US
Mailing Address - Phone:937-877-7863
Mailing Address - Fax:
Practice Address - Street 1:701 FIVE OAKS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-5218
Practice Address - Country:US
Practice Address - Phone:937-877-7863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH187586101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)