Basic Information
| Provider Information | |||||||||
| NPI: | 1316373715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTHARD | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOUTHARD | ||||||||
| OtherFirstName: | KATHYLENE | ||||||||
| OtherMiddleName: | CASTILLO | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 161 HAMPSHIRE ST | ||||||||
| Address2: | APT 3R | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021391321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187538503 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | KAHI MOHALA BEHAVIORAL HEALTH, 2301 OLD FORT WEAVER RD | ||||||||
| Address2: | |||||||||
| City: | EWA BEACH | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086718511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2013 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 118839 | MA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | HI-4271 | HI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.