MEDICARE: STEPHANIE SOUTHARD LCSW

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	1041C0700X	Clinical Social Worker	73072535	NY

General Provider Information

NPI Number	:	1952060824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE SOUTHARD LCSW

Provider Business Mailing Address
First Line	:	44 GROVELAND PARK BLVD
Second Line	:
City	:	SOUND BEACH
State	:	NY
Zip	:	11789-2540
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	44 GROVELAND PARK BLVD
Second Line	:
City	:	SOUND BEACH
State	:	NY
Zip	:	11789-2540
Country	:	US
Telephone Number	:	631-745-5150
Fax Number	:

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

Provider Enumeration Date	:	12/08/2021
Last Update Date	:	12/08/2021

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Directions to “ STEPHANIE SOUTHARD LCSW” Practice Location

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