Provider Demographics
NPI:1407353964
Name:ALFRED, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ALFRED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-7237
Mailing Address - Country:US
Mailing Address - Phone:985-626-4553
Mailing Address - Fax:
Practice Address - Street 1:1325 W CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3043
Practice Address - Country:US
Practice Address - Phone:985-272-1825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician