MEDICARE: GREGORY SOUTHARD IMFT-S, LPCC-S

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	F.2100158-SUPV	OH
2	106H00000X	Marriage & Family Therapist	M1900095	OH
3	101YM0800X	Mental Health Counselor	E.2001739	OH
4	101YM0800X	Mental Health Counselor

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1588183453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY SOUTHARD IMFT-S, LPCC-S

Provider Business Mailing Address
First Line	:	4522 FULTON DR NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-2332
Country	:	US
Telephone Number	:	330-915-2907
Fax Number	:	330-915-2958

Provider Business Practice Location Address
First Line	:	4522 FULTON DR NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44718-2332
Country	:	US
Telephone Number	:	330-915-2907
Fax Number	:	330-915-2958

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	04/29/2026

2050 CUMMING HWY , SUITE 100
CANTON, GA
30114-8614

Practice Phone: 770-345-9600
Practice Fax:

4522 FULTON DR NW
CANTON, OH
44718-2332