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General NPI Number Information
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NPI Number | 1235313719
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Entity Type | Individual
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Provider Name | SUSAN MARIE SOUTHWORTH PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 12/20/2007
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Last Update Date | 07/12/2013
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Provider Practice Location Address
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Address Line | 310 S PLATTE CLAY WAY SUITE C
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City | KEARNEY
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State | MO
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Zip | 64060-8797
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Country | US
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Telephone | 816-914-5322
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Fax | 816-628-5452
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Provider Business Mailing Address
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Address Line | 310 S PLATTE CLAY WAY SUITE C
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City | KEARNEY
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State | MO
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Zip | 64060-8797
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Country | US
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Telephone | 816-914-5322
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Fax | 816-628-5452
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY01928
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License Number State | MO
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