Provider Demographics
NPI:1962249078
Name:SOUTHERLAND, AKUA
Entity type:Individual
Prefix:
First Name:AKUA
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10911 WOODMEADOW PKWY APT 913
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-7359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5706 ROWLETT RD STE 500
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75089-3463
Practice Address - Country:US
Practice Address - Phone:855-782-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician