Provider Demographics
NPI:1922470160
Name:RIDEAU, TRAVON
Entity Type:Individual
Prefix:
First Name:TRAVON
Middle Name:
Last Name:RIDEAU
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 1:209 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6256
Mailing Address - Country:US
Mailing Address - Phone:337-942-6400
Mailing Address - Fax:
Practice Address - Street 1:209 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6256
Practice Address - Country:US
Practice Address - Phone:337-942-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
101YM0800X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst