Provider Demographics
NPI:1407048648
Name:MANDAL-BLASIO, REBECCA LYNN (PHD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LYNN
Last Name:MANDAL-BLASIO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 CITRUS BLVD STE A1
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70123-8505
Mailing Address - Country:US
Mailing Address - Phone:866-727-8274
Mailing Address - Fax:
Practice Address - Street 1:5700 CITRUS BLVD STE A1
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70123-8505
Practice Address - Country:US
Practice Address - Phone:866-727-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-12
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA932103TM1800X, 103TM1800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst