Provider Demographics
NPI:1700849148
Name:SOUTH, CAROLYN S (LPC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:S
Last Name:SOUTH
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-0549
Mailing Address - Country:US
Mailing Address - Phone:804-699-3238
Mailing Address - Fax:804-699-3731
Practice Address - Street 1:6558 MAIN STREET
Practice Address - Street 2:MORGAN BLDG., STE 1 OFFICE 3 AND 3A
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4162
Practice Address - Country:US
Practice Address - Phone:804-699-3238
Practice Address - Fax:804-699-3731
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717000854106H00000X
VA0701001882101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000000000000Medicaid
VA250214OtherANTHEM
VA250214Medicaid
VA324680OtherTRICARE
VAO85674OtherSOUTHERN HEALTH
VA7274243OtherAETNA
VAO85674Medicaid
VA409486OtherVALUE OPTIONS