1356304380 NPI number — MR. LARRY E SOUTHARD MA MFT

Table of content: (NPI 1245375492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356304380 NPI number — MR. LARRY E SOUTHARD MA MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHARD
Provider First Name:
LARRY
Provider Middle Name:
E
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA MFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356304380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1255 E HIGHLAND AVE
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-881-5250
Provider Business Mailing Address Fax Number:
909-337-2724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-881-5250
Provider Business Practice Location Address Fax Number:
909-337-2724
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC18620 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 061147 . This is a "HEALTHNET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 065571 . This is a "MANAGED HEALTH NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 186380 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 33B61D . This is a "RIVERSIDE CNTY BEHAVIORAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5362524 . This is a "AETNA BEHAVIORAL HEALTH P" identifier . This identifiers is of the category "OTHER".
  • Identifier: 019346 . This is a "VMC BEHAVIORAL HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 56862099802 . This is a "PACIFICARE BEHAVIORAL HEA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3112 . This is a "CONCERN EAP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 386213 . This is a "VALUE OPTIONS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6270815 . This is a "US BEHAVIORAL HEALTH PLAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 208994 . This is a "CIGNA BEHAVIORAL HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: MFT18620 . This is a "BLUE SHIELD OF CA" identifier . This identifiers is of the category "OTHER".




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