Provider Demographics
NPI:1134109226
Name:RIGONI-SOUTHLAND, MARYANN (MA, LLP, LLPC, NCC)
Entity type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:
Last Name:RIGONI-SOUTHLAND
Suffix:
Gender:F
Credentials:MA, LLP, LLPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2282
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2282
Mailing Address - Country:US
Mailing Address - Phone:269-743-6139
Mailing Address - Fax:269-290-7512
Practice Address - Street 1:3054 S 9TH ST
Practice Address - Street 2:STE B
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6250
Practice Address - Country:US
Practice Address - Phone:269-743-6139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011550103TC1900X
MI6401008766101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301011550OtherLLP LICENSE #
MI6401008766OtherLLPC LICENSE #
54949OtherNBCC #