Provider Demographics
NPI:1770813024
Name:SOUTHWARD, JOHN ELMER (MA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ELMER
Last Name:SOUTHWARD
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9788 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DESCANSO
Mailing Address - State:CA
Mailing Address - Zip Code:91916-9761
Mailing Address - Country:US
Mailing Address - Phone:619-980-7764
Mailing Address - Fax:
Practice Address - Street 1:9788 RIVER DR STE 208
Practice Address - Street 2:
Practice Address - City:DESCANSO
Practice Address - State:CA
Practice Address - Zip Code:91916-9761
Practice Address - Country:US
Practice Address - Phone:619-980-7764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-09
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47976106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist