Provider Demographics
NPI:1982890083
Name:SOUTHERLAND, LISA K
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W 2ND ST STE 517
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72201-2510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 W 2ND ST STE 517
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72201-2510
Practice Address - Country:US
Practice Address - Phone:501-213-7556
Practice Address - Fax:501-663-2234
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2145-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical