Provider Demographics
NPI:1063753994
Name:SOUTAR, ASHLEY (MS, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SOUTAR
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2943
Mailing Address - Country:US
Mailing Address - Phone:313-498-1685
Mailing Address - Fax:
Practice Address - Street 1:707 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2943
Practice Address - Country:US
Practice Address - Phone:313-498-1685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015435103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7401000088OtherBEHAVIOR ANALYST LICENSE
1-13-13325OtherBCBA