Provider Demographics
NPI:1225641301
Name:WOLDT, KARLY (BCBA)
Entity Type:Individual
Prefix:
First Name:KARLY
Middle Name:
Last Name:WOLDT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N9594 COUNTY ROAD PP
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110
Mailing Address - Country:US
Mailing Address - Phone:920-360-1361
Mailing Address - Fax:
Practice Address - Street 1:4797 W GRANDE MARKET DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8411
Practice Address - Country:US
Practice Address - Phone:920-815-3873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1093140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst