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General NPI Number Information
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NPI Number | 1841688272
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Entity Type | Organization
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Legal Business Name | SOUTHERN COUNSELING AND PSYCHOLOGICAL SERVICES LLC
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Dates
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Enumeration Date | 01/08/2015
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 104 E LINDA VISTA BLVD STE B
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City | ROSWELL
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State | NM
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Zip | 88201-6667
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Country | US
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Telephone | 575-624-8889
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3391
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City | ROSWELL
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State | NM
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Zip | 88202-3391
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Country | US
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Telephone | 575-624-8889
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST/OWNER
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Name | DR. DOUGLAS STEPHEN SOUTHERN
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Credential | PH.D.
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Telephone | 575-420-1853
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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 | 1353
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License Number State | NM
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