MEDICARE: ALYSSA SOUTHARD RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1770361321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA SOUTHARD RBT

Provider Business Mailing Address
First Line	:	215 RED COACH DR
Second Line	:
City	:	MISHAWAKA
State	:	IN
Zip	:	46545-8307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	614 N 6TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62702-5313
Country	:	US
Telephone Number	:	574-387-4313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2023
Last Update Date	:	09/15/2023

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Directions to “ ALYSSA SOUTHARD RBT” Practice Location

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