Provider Demographics
NPI:1962625020
Name:SOUTHERTON, AMBER (MSW, LLMSW)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:SOUTHERTON
Suffix:
Gender:F
Credentials:MSW, LLMSW
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 279
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:MI
Mailing Address - Zip Code:48742-0279
Mailing Address - Country:US
Mailing Address - Phone:989-736-8157
Mailing Address - Fax:
Practice Address - Street 1:177 N BARLOW RD
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48740-9607
Practice Address - Country:US
Practice Address - Phone:989-736-8157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010854701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical