Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | LCP 128 | KS |
N | 103T00000X | Psychologist | LCP 128 | KS |
N | 103TB0200X | Cognitive & Behavioral Psychologist | LMLP 0495 | KS |
NPI | 1184676702 |
---|---|
Provider Name | Lisa M Southern |
First Address | Garden City, KS 67846-5870 |
Second Address | Garden City, KS 67846-5870 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2006 |
Last Update Date | 08/07/2007 |