Provider Demographics
NPI:1750764759
Name:CARLILE, GWENDOLYN SUZANNE (BCBA)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:SUZANNE
Last Name:CARLILE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:BAYARD
Other - Last Name:CARLILE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:2519 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7323
Mailing Address - Country:US
Mailing Address - Phone:337-491-0800
Mailing Address - Fax:337-491-0805
Practice Address - Street 1:2519 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7323
Practice Address - Country:US
Practice Address - Phone:337-491-0800
Practice Address - Fax:337-491-0805
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst