Provider Demographics
NPI:1285983932
Name:SOUTHWELL, SUSIE I (MED)
Entity type:Individual
Prefix:MS
First Name:SUSIE
Middle Name:I
Last Name:SOUTHWELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MS
Other - First Name:SUZANNE
Other - Middle Name:I
Other - Last Name:SOUTHWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:M ED
Mailing Address - Street 1:9320 BROUGHTON CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-2224
Mailing Address - Country:US
Mailing Address - Phone:405-760-1798
Mailing Address - Fax:
Practice Address - Street 1:10948 N MAY AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6224
Practice Address - Country:US
Practice Address - Phone:580-364-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120SMedicaid