Provider Demographics
NPI:1104473222
Name:SOUTHERN, DANIELLE (CB)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:CB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 NW GILMAN BLVD # 2604
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5394
Mailing Address - Country:US
Mailing Address - Phone:805-668-8961
Mailing Address - Fax:208-416-6922
Practice Address - Street 1:1420 NW GILMAN BLVD # 2604
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5394
Practice Address - Country:US
Practice Address - Phone:805-668-8961
Practice Address - Fax:208-416-6922
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB60997173106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACB60997173OtherSTATE LICENSE