Provider Demographics
NPI:1225904584
Name:SOUTHARD, MEGAN LAURAINE
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LAURAINE
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LAURAINE
Other - Last Name:PIERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4135 ALTAMONT DR
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-7270
Mailing Address - Country:US
Mailing Address - Phone:541-591-0328
Mailing Address - Fax:
Practice Address - Street 1:115 N 10TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-5803
Practice Address - Country:US
Practice Address - Phone:541-591-2680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113435175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist