Healthcare Provider Details

I. General information

NPI: 1508728916
Provider Name (Legal Business Name): RICKI SOUTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 TERMINAL DR
RICHLAND WA
99354-4953
US

IV. Provider business mailing address

1212 FONTANA CT
RICHLAND WA
99354-2114
US

V. Phone/Fax

Practice location:
  • Phone: 360-984-3131
  • Fax: 360-718-8542
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCB70064036
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: