Provider Demographics
NPI:1316091713
Name:SOUTHWORTH, NORMA M (PHD)
Entity type:Individual
Prefix:DR
First Name:NORMA
Middle Name:M
Last Name:SOUTHWORTH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NORMA
Other - Middle Name:
Other - Last Name:SOUTHWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:57 WEST 75TH STREET
Mailing Address - Street 2:APT 5C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2008
Mailing Address - Country:US
Mailing Address - Phone:212-877-0039
Mailing Address - Fax:212-239-0948
Practice Address - Street 1:19 WEST 34TH STREET
Practice Address - Street 2:PENTHOUSE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3006
Practice Address - Country:US
Practice Address - Phone:212-877-0039
Practice Address - Fax:212-239-0948
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007859103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical