Provider Demographics
NPI:1952706475
Name:SOUTHARD, TERRI (MS, LPC)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:MS, LPC
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:5133 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6338
Practice Address - Country:US
Practice Address - Phone:843-789-1786
Practice Address - Fax:843-958-1263
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2264101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1446Medicaid