Provider Demographics
NPI:1710685771
Name:BORDELON, ALYSON ROSE
Entity Type:Individual
Prefix:
First Name:ALYSON
Middle Name:ROSE
Last Name:BORDELON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 BECKY DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:LA
Mailing Address - Zip Code:70094-2808
Mailing Address - Country:US
Mailing Address - Phone:504-452-1293
Mailing Address - Fax:
Practice Address - Street 1:42124 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1427
Practice Address - Country:US
Practice Address - Phone:985-500-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst