Provider Demographics
NPI:1306660469
Name:WILLIAMS SOUTHALL, LUCRETIA MICHELLE
Entity type:Individual
Prefix:
First Name:LUCRETIA
Middle Name:MICHELLE
Last Name:WILLIAMS SOUTHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7941 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1953
Mailing Address - Country:US
Mailing Address - Phone:317-430-5335
Mailing Address - Fax:
Practice Address - Street 1:7941 CASTLEWAY DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1953
Practice Address - Country:US
Practice Address - Phone:317-430-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN108841176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health