Provider Demographics
NPI:1932500691
Name:SOUTHERN, LOUISE
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:SOUTHERN
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 1:505 OBERLIN RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1327
Mailing Address - Country:US
Mailing Address - Phone:919-743-0204
Mailing Address - Fax:
Practice Address - Street 1:505 OBERLIN RD
Practice Address - Street 2:SUITE 230
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1327
Practice Address - Country:US
Practice Address - Phone:919-743-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1095534103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408612Medicaid