Healthcare Provider Details

I. General information

NPI: 1922453380
Provider Name (Legal Business Name): DONNELL SOUTHALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 MYERS ST
RIVERSIDE CA
92503-5527
US

IV. Provider business mailing address

3840 MYERS ST
RIVERSIDE CA
92503-3614
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4840
  • Fax:
Mailing address:
  • Phone: 951-515-5844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: