1700398534 NPI number — CHRISTINA LOUISE FOURNIER-SOUTHERN LCSW

Table of content: CHRISTINA LOUISE FOURNIER-SOUTHERN LCSW (NPI 1700398534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700398534 NPI number — CHRISTINA LOUISE FOURNIER-SOUTHERN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOURNIER-SOUTHERN
Provider First Name:
CHRISTINA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1700398534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
571 S ALLEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAT ROCK
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28731-9447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-692-6178
Provider Business Mailing Address Fax Number:
828-692-2365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
571 S ALLEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAT ROCK
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-692-6178
Provider Business Practice Location Address Fax Number:
828-692-2365
Provider Enumeration Date:
11/02/2017

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: 104100000X , with the licence number:  C003814 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: C003814 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C003814 . This is a "LICENSED CLINICAL SOCIAL WORKER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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