Provider Demographics
NPI:1851800221
Name:FANDAL, MALLORY ANNE (MA PBA, BCABA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:FANDAL
Suffix:
Gender:F
Credentials:MA PBA, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3999 HIGHWAY 190 EAST SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4914
Mailing Address - Country:US
Mailing Address - Phone:985-871-0689
Mailing Address - Fax:
Practice Address - Street 1:3999 HIGHWAY 190 EAST SERVICE RD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4914
Practice Address - Country:US
Practice Address - Phone:985-871-0689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAC015106E00000X
LAL-271103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst