MEDICARE: MR. WILLIAM D SOUTHER MSW, LICSW

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	7484	MN

General Provider Information

NPI Number	:	1649315466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM D SOUTHER MSW, LICSW

Provider Business Mailing Address
First Line	:	4989 355TH ST
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-5581
Country	:	US
Telephone Number	:	651-237-0803
Fax Number	:

Provider Business Practice Location Address
First Line	:	5833 PECAN ST
Second Line	:	SUITE A2
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-6689
Country	:	US
Telephone Number	:	651-237-0628
Fax Number	:	651-237-0631

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

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	07/08/2007

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