Provider Demographics
NPI:1942396205
Name:SOUTH, LINDSAY PAGE (MA)
Entity Type:Individual
Prefix:MS
First Name:LINDSAY
Middle Name:PAGE
Last Name:SOUTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1591 W CENTRE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-323-2553
Mailing Address - Fax:289-323-2558
Practice Address - Street 1:1591 W CENTRE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-323-2553
Practice Address - Fax:289-323-2558
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005843101YM0800X
MI6301007223103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN