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General NPI Number Information
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NPI Number | 1750407425
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Entity Type | Individual
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Provider Name | MICHELLE CAROL SOUTHERLY SLP
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Gender | Female
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Dates
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Enumeration Date | 03/22/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | RR 1 BOX 34 A
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City | AUGUSTA
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State | WV
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Zip | 26704-9706
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Country | US
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Telephone | 304-496-8284
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Fax | 304-496-9761
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Provider Business Mailing Address
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Address Line | RR 1 BOX 34 A
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City | AUGUSTA
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State | WV
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Zip | 26704-9706
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Country | US
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Telephone | 304-496-8284
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Fax | 304-496-9761
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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 | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 394
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License Number State | WV
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