Provider Demographics
NPI:1316746530
Name:SOUTHERN, PHILIP (APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:SOUTHERN
Suffix:
Gender:
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3626 WILLIAMS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-4092
Mailing Address - Country:US
Mailing Address - Phone:888-374-5066
Mailing Address - Fax:303-200-8356
Practice Address - Street 1:3626 WILLIAMS DR STE 100
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-4092
Practice Address - Country:US
Practice Address - Phone:888-374-5066
Practice Address - Fax:512-233-2751
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1190401363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health