Provider Demographics
NPI:1780188573
Name:SOUTH, BIENVILLE
Entity Type:Individual
Prefix:
First Name:BIENVILLE
Middle Name:
Last Name:SOUTH
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 1:3660 W SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-2931
Mailing Address - Country:US
Mailing Address - Phone:323-214-9166
Mailing Address - Fax:
Practice Address - Street 1:3660 W SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2931
Practice Address - Country:US
Practice Address - Phone:323-214-9166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 103TA0400X, 101YP1600X, 103K00000X, 103TM1800X, 171000000X, 171M00000X, 172A00000X, 174N00000X, 221700000X, 104100000X
CA103TF0000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No171000000XOther Service ProvidersMilitary Health Care Provider
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist