Healthcare Provider Details

I. General information

NPI: 1649691924
Provider Name (Legal Business Name): DONNA SOUTHARD MA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 177TH ST
LANSING IL
60438-1722
US

IV. Provider business mailing address

1701 FORSYTHIA ST SE
DEMOTTE IN
46310-8264
US

V. Phone/Fax

Practice location:
  • Phone: 708-895-7310
  • Fax:
Mailing address:
  • Phone: 219-472-1757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003601
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: