Provider Demographics
NPI:1700629326
Name:SOUTHAM, NATASHA
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:SOUTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:
Other - Last Name:MARTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1615 CAPITOL WAY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-204-7870
Mailing Address - Fax:701-491-7505
Practice Address - Street 1:1615 CAPITOL WAY
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-204-7870
Practice Address - Fax:701-491-7505
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-353554106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician