Provider Demographics
NPI:1841688272
Name:SOUTHERN COUNSELING AND PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:SOUTHERN COUNSELING AND PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:SOUTHERN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:575-420-1853
Mailing Address - Street 1:PO BOX 3391
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-3391
Mailing Address - Country:US
Mailing Address - Phone:575-624-8889
Mailing Address - Fax:
Practice Address - Street 1:104 E LINDA VISTA BLVD STE B
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6667
Practice Address - Country:US
Practice Address - Phone:575-624-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1353103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10180087Medicaid