Healthcare Provider Details

I. General information

NPI: 1255950648
Provider Name (Legal Business Name): LIZA SOUTHERTON MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 11/15/2025
Certification Date: 11/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 LUCERNE TER
ORLANDO FL
32806-1013
US

IV. Provider business mailing address

2502 RIVERSIDE PKWY APT 928
GRAND PRAIRIE TX
75050-7980
US

V. Phone/Fax

Practice location:
  • Phone: 407-894-1444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: