Provider Demographics
NPI:1518754423
Name:SOUTHALL, SANTANA ANGEL
Entity type:Individual
Prefix:
First Name:SANTANA
Middle Name:ANGEL
Last Name:SOUTHALL
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 1:3316 E RANCIER AVE APT 10208
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-4110
Mailing Address - Country:US
Mailing Address - Phone:219-895-0946
Mailing Address - Fax:
Practice Address - Street 1:3000 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5371
Practice Address - Country:US
Practice Address - Phone:254-402-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician