Provider Demographics
NPI:1447312152
Name:SOUTHWARD, T
Entity type:Individual
Prefix:
First Name:T
Middle Name:
Last Name:SOUTHWARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6808 N WOLCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6808 N WOLCOTT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-3155
Practice Address - Country:US
Practice Address - Phone:773-456-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2009-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst