Provider Demographics
NPI:1932642014
Name:SOUTHWOOD, AMELIE (LMHC)
Entity Type:Individual
Prefix:MS
First Name:AMELIE
Middle Name:
Last Name:SOUTHWOOD
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HAVEN CT
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1933
Mailing Address - Country:US
Mailing Address - Phone:646-267-1346
Mailing Address - Fax:
Practice Address - Street 1:16 HAVEN CT
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1933
Practice Address - Country:US
Practice Address - Phone:646-267-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007529101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
13915405OtherCAQH