Provider Demographics
NPI:1316373715
Name:SOUTHARD, KATHY (LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KATHYLENE
Other - Middle Name:CASTILLO
Other - Last Name:SOUTHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:161 HAMPSHIRE ST
Mailing Address - Street 2:APT 3R
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1321
Mailing Address - Country:US
Mailing Address - Phone:718-753-8503
Mailing Address - Fax:
Practice Address - Street 1:KAHI MOHALA BEHAVIORAL HEALTH, 2301 OLD FORT WEAVER RD
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706
Practice Address - Country:US
Practice Address - Phone:808-671-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1188391041C0700X
HIHI-42711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical