Provider Demographics
NPI:1710196563
Name:SOUTHARD, WILLIAM MICHAEL
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 7TH ST W
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-6427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1412
Practice Address - Country:US
Practice Address - Phone:707-944-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ14340ZMedicare ID - Type Unspecified
CAR21218Medicare UPIN