Provider Demographics
NPI:1790392082
Name:SOUTHERS, CORRYN
Entity Type:Individual
Prefix:
First Name:CORRYN
Middle Name:
Last Name:SOUTHERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14024 COGSWELL ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-1023
Mailing Address - Country:US
Mailing Address - Phone:734-672-1388
Mailing Address - Fax:
Practice Address - Street 1:1423 FIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2321
Practice Address - Country:US
Practice Address - Phone:313-924-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker