Provider Demographics
NPI:1871625590
Name:SOUTHWORTH, LISA ANNE (LPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 LAUREL ST.
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2624
Mailing Address - Country:US
Mailing Address - Phone:803-765-0700
Mailing Address - Fax:803-765-1607
Practice Address - Street 1:1709 LAUREL ST.
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2624
Practice Address - Country:US
Practice Address - Phone:803-765-0700
Practice Address - Fax:803-765-1607
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3419101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional