Healthcare Provider Details

I. General information

NPI: 1649192436
Provider Name (Legal Business Name): RAQUELLE R SOUTHARD SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 VETERANS PKWY STE 210
COLUMBUS GA
31904-3465
US

IV. Provider business mailing address

3071 WILLIAMS RD APT 165
COLUMBUS GA
31909-5688
US

V. Phone/Fax

Practice location:
  • Phone: 706-641-7313
  • Fax:
Mailing address:
  • Phone: 318-664-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP014236
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: