Provider Demographics
NPI:1992426662
Name:FONTENOT, AMELIA LAFARGUE (MA, LBA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:AMELIA
Middle Name:LAFARGUE
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:MA, LBA, BCBA
Other - Prefix:MS
Other - First Name:AMELIA
Other - Middle Name:GRACE
Other - Last Name:LAFARGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27500 KINGS FARM RD
Mailing Address - Street 2:
Mailing Address - City:KINDER
Mailing Address - State:LA
Mailing Address - Zip Code:70648-4217
Mailing Address - Country:US
Mailing Address - Phone:318-335-8382
Mailing Address - Fax:
Practice Address - Street 1:4019 COMMON ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-2942
Practice Address - Country:US
Practice Address - Phone:337-377-6206
Practice Address - Fax:866-399-7694
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-659103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst