Provider Demographics
NPI:1356602403
Name:SOUTHARD, LINDA DIANE (MSED,BCABA)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DIANE
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:MSED,BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 SECATOGUE AVE
Mailing Address - Street 2:UNIT 16
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-1984
Mailing Address - Country:US
Mailing Address - Phone:516-655-0686
Mailing Address - Fax:516-379-6053
Practice Address - Street 1:81 SECATOGUE AVE
Practice Address - Street 2:UNIT 16
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-1984
Practice Address - Country:US
Practice Address - Phone:516-655-0686
Practice Address - Fax:516-379-6053
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst