Healthcare Provider Details

I. General information

NPI: 1629695291
Provider Name (Legal Business Name): BERYL D SOUTHALL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3986 COUNTY ROAD 454
EL CAMPO TX
77437-6640
US

IV. Provider business mailing address

3986 COUNTY ROAD 454
EL CAMPO TX
77437-6640
US

V. Phone/Fax

Practice location:
  • Phone: 979-997-0527
  • Fax:
Mailing address:
  • Phone: 979-997-0527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number77657
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: