Basic Information
| Provider Information | |||||||||
| NPI: | 1871638296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTHERN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 913 NW GARDEN VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974716523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414401000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 612 SE JACKSON ST STE 11 | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974704956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414646455 | ||||||||
| FaxNumber: | 5414646457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 4143 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.