Basic Information
| Provider Information | |||||||||
| NPI: | 1982890083 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTHERLAND | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 W 2ND ST STE 517 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722012510 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 221 W 2ND ST STE 517 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722012510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012137556 | ||||||||
| FaxNumber: | 5016632234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2145-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.