Provider Demographics
NPI:1962298463
Name:KINN-SOUTHWORTH, SANDRA MARLEEN
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:MARLEEN
Last Name:KINN-SOUTHWORTH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 BLACKLICK EASTERN RD
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-8235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2358 PEMBERTON DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3147
Practice Address - Country:US
Practice Address - Phone:419-297-2962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-19
Last Update Date:2025-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical