Provider Demographics
NPI:1922567536
Name:SOUTHERLAND, KIRSTEN RHEA
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:RHEA
Last Name:SOUTHERLAND
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 1:3231 OLD 63 S
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5369
Mailing Address - Country:US
Mailing Address - Phone:573-823-5291
Mailing Address - Fax:
Practice Address - Street 1:600 E STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65211-0001
Practice Address - Country:US
Practice Address - Phone:573-882-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer