Provider Demographics
NPI:1962489120
Name:SOUTHERLAND, DEBORAH LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:LYNN
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1572 OTTERCREEK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-2856
Mailing Address - Country:US
Mailing Address - Phone:513-674-0900
Mailing Address - Fax:513-648-0156
Practice Address - Street 1:230 NORTHLAND BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3675
Practice Address - Country:US
Practice Address - Phone:513-670-9000
Practice Address - Fax:513-648-0156
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4118103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0722132Medicaid
OHSOCP06171Medicare ID - Type Unspecified