Provider Demographics
NPI:1689052912
Name:SOUTHERN, KATHRYN L (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:L
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11399 MASTERS RD
Mailing Address - Street 2:
Mailing Address - City:RILEY
Mailing Address - State:MI
Mailing Address - Zip Code:48041-2604
Mailing Address - Country:US
Mailing Address - Phone:586-817-3997
Mailing Address - Fax:
Practice Address - Street 1:2314 YORKSHIRE RD STE 200
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5041
Practice Address - Country:US
Practice Address - Phone:734-973-9670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist