Provider Demographics
NPI:1821449257
Name:SOUTHERLAND, CHRISTY LYNN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:LYNN
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 W MICHIGAN AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1432
Mailing Address - Country:US
Mailing Address - Phone:269-657-6025
Mailing Address - Fax:269-657-5198
Practice Address - Street 1:181 W MICHIGAN AVE STE 3
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1432
Practice Address - Country:US
Practice Address - Phone:269-657-6025
Practice Address - Fax:269-657-5198
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010938101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional