Provider Demographics
NPI:1285708412
Name:SOUTHERN, JAMES H JR (LPC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:H
Last Name:SOUTHERN
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-9569
Mailing Address - Country:US
Mailing Address - Phone:252-473-6436
Mailing Address - Fax:
Practice Address - Street 1:2808 S CROATAN HWY
Practice Address - Street 2:SUITE A
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-9024
Practice Address - Country:US
Practice Address - Phone:252-449-4011
Practice Address - Fax:252-449-4050
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3091101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC138TYOtherBCBS PROVIDER NUMBER
NC6102181Medicaid