Provider Demographics
NPI:1245955731
Name:SOUTHALL, DAVID (LPC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SOUTHALL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 BRANDON AVE SW # 1115
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-1490
Mailing Address - Country:US
Mailing Address - Phone:540-342-1261
Mailing Address - Fax:
Practice Address - Street 1:3807 BRANDON AVE SW # 1115
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-1490
Practice Address - Country:US
Practice Address - Phone:540-342-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011817101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional