Healthcare Provider Details

I. General information

NPI: 1588183453
Provider Name (Legal Business Name): GREGORY SOUTHARD IMFT-S, LPCC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4522 FULTON DR NW
CANTON OH
44718-2332
US

IV. Provider business mailing address

4522 FULTON DR NW
CANTON OH
44718-2332
US

V. Phone/Fax

Practice location:
  • Phone: 330-915-2907
  • Fax: 330-915-2958
Mailing address:
  • Phone: 330-915-2907
  • Fax: 330-915-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberF.2100158-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM1900095
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2001739
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: