1356602403 NPI number — MRS. LINDA DIANE SOUTHARD MSED,BCABA

Table of content: MRS. LINDA DIANE SOUTHARD MSED,BCABA (NPI 1356602403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356602403 NPI number — MRS. LINDA DIANE SOUTHARD MSED,BCABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOUTHARD
Provider First Name:
LINDA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSED,BCABA
Provider Gender Code:
F

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:
1356602403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
81 SECATOGUE AVE
Provider Second Line Business Mailing Address:
UNIT 16
Provider Business Mailing Address City Name:
FARMINGDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11735-1984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-655-0686
Provider Business Mailing Address Fax Number:
516-379-6053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
81 SECATOGUE AVE
Provider Second Line Business Practice Location Address:
UNIT 16
Provider Business Practice Location Address City Name:
FARMINGDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11735-1984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-655-0686
Provider Business Practice Location Address Fax Number:
516-379-6053
Provider Enumeration Date:
06/05/2012

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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