Provider Demographics
NPI:1871638296
Name:SOUTHERN, KELLY ANNE (MSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 NW GARDEN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6523
Mailing Address - Country:US
Mailing Address - Phone:541-440-1000
Mailing Address - Fax:
Practice Address - Street 1:612 SE JACKSON ST STE 11
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-4956
Practice Address - Country:US
Practice Address - Phone:541-464-6455
Practice Address - Fax:541-464-6457
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR41431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical