Provider Demographics
NPI:1952851875
Name:SOUTHALL, KATHERINE C
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:C
Last Name:SOUTHALL
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 1:484 WOODBINE CIR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44143-1525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:484 WOODBINE CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44143-1525
Practice Address - Country:US
Practice Address - Phone:440-221-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-16-22792103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst