Provider Demographics
NPI:1588434096
Name:SOUTHWICK, ISAAC A
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:A
Last Name:SOUTHWICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 MISTY MEADOWS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020
Mailing Address - Country:US
Mailing Address - Phone:573-480-0261
Mailing Address - Fax:
Practice Address - Street 1:172 DARE BLVD
Practice Address - Street 2:
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-5558
Practice Address - Country:US
Practice Address - Phone:573-346-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220381482355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant