Provider Demographics
NPI:1538235908
Name:SOUTHWELL, GARY DANIEL (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DANIEL
Last Name:SOUTHWELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9643 39TH LOOP NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6230
Mailing Address - Country:US
Mailing Address - Phone:360-951-8647
Mailing Address - Fax:
Practice Address - Street 1:9643 39TH LOOP NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-6230
Practice Address - Country:US
Practice Address - Phone:360-951-8647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1655103TC0700X
WAPY 60423359103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical