Provider Demographics
NPI:1699295857
Name:SOUTHARD, CARLYNN EZ (BCBA)
Entity type:Individual
Prefix:
First Name:CARLYNN
Middle Name:EZ
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CARLYNN
Other - Middle Name:E
Other - Last Name:ZAHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 FOURIER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1969
Mailing Address - Country:US
Mailing Address - Phone:608-662-9327
Mailing Address - Fax:608-662-9041
Practice Address - Street 1:1210 FOURIER DR STE 100
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1969
Practice Address - Country:US
Practice Address - Phone:608-662-9327
Practice Address - Fax:608-662-9041
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst