Healthcare Provider Details

I. General information

NPI: 1104759950
Provider Name (Legal Business Name): ELIZABETH M. SOUTHERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 RIVERCHASE PKWY E
HOOVER AL
35244-2899
US

IV. Provider business mailing address

4715 THORNHILL RD
GARDENDALE AL
35071-4732
US

V. Phone/Fax

Practice location:
  • Phone: 205-675-0529
  • Fax:
Mailing address:
  • Phone: 205-285-4527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC05988
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: