Provider Demographics
NPI:1831313501
Name:SOUTHARD, CHRIS KEITH (MA)
Entity Type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:KEITH
Last Name:SOUTHARD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 AVOCADO VISTA LN
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-7868
Mailing Address - Country:US
Mailing Address - Phone:760-451-0833
Mailing Address - Fax:760-451-0833
Practice Address - Street 1:10717 CAMINO RUIZ
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2360
Practice Address - Country:US
Practice Address - Phone:858-566-5740
Practice Address - Fax:858-566-6430
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34920106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist