MEDICARE: MS. MARYANN RIGONI-SOUTHLAND MA, LLP, LLPC, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	6301011550	MI
2	101YP2500X	Professional Counselor	6401008766	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6301011550	OTHER	MI	LLP LICENSE #
2	6401008766	OTHER	MI	LLPC LICENSE #
3	54949	OTHER		NBCC #

General Provider Information

NPI Number	:	1134109226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARYANN RIGONI-SOUTHLAND MA, LLP, LLPC, NCC

Provider Business Mailing Address
First Line	:	PO BOX 2282
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49081-2282
Country	:	US
Telephone Number	:	269-743-6139
Fax Number	:	269-290-7512

Provider Business Practice Location Address
First Line	:	3054 S 9TH ST
Second Line	:	STE B
City	:	KALAMAZOO
State	:	MI
Zip	:	49009-6250
Country	:	US
Telephone Number	:	269-743-6139
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2006
Last Update Date	:	12/20/2019

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