Provider Demographics
NPI:1750834701
Name:SUSAN SOUTHWORTH, PSY.D. LLC
Entity Type:Organization
Organization Name:SUSAN SOUTHWORTH, PSY.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SOUTHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:816-903-3800
Mailing Address - Street 1:302 S CLAY WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060
Mailing Address - Country:US
Mailing Address - Phone:816-903-3800
Mailing Address - Fax:816-903-9999
Practice Address - Street 1:302 S PLATTE CLAY WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-8500
Practice Address - Country:US
Practice Address - Phone:816-903-3800
Practice Address - Fax:816-903-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01928103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1235313719Medicaid
MOD76000002Medicare PIN