Provider Demographics
NPI:1699248054
Name:SOUTHARD, LISA (LMSW, LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 795
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617
Mailing Address - Country:US
Mailing Address - Phone:208-365-1406
Mailing Address - Fax:
Practice Address - Street 1:825 S. WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617
Practice Address - Country:US
Practice Address - Phone:208-365-3141
Practice Address - Fax:208-398-8311
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDIDLCSW309941041C0700X
CACALCSW272791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical