Provider Demographics
NPI:1942800172
Name:BOYDSTUN, MADISON VLAHAKIS
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:VLAHAKIS
Last Name:BOYDSTUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:VLAHAKIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1823
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-1823
Mailing Address - Country:US
Mailing Address - Phone:318-588-8908
Mailing Address - Fax:
Practice Address - Street 1:4440 VIKING DR STE 400
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7511
Practice Address - Country:US
Practice Address - Phone:318-245-4113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC-80OtherSTATE CERTIFICATION ASSISTANT BEHAVIOR ANALYST