Provider Demographics
NPI:1528417045
Name:BONVILLAIN, MANDI GAUBERT (SSP, NCSP, BCBA)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:GAUBERT
Last Name:BONVILLAIN
Suffix:
Gender:F
Credentials:SSP, NCSP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 VERRETT STREET
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360
Mailing Address - Country:US
Mailing Address - Phone:985-873-6092
Mailing Address - Fax:
Practice Address - Street 1:1018 VERRETT STREET
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360
Practice Address - Country:US
Practice Address - Phone:985-873-6092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool