1942800172 NPI number — MADISON VLAHAKIS BOYDSTUN

Table of content: MADISON VLAHAKIS BOYDSTUN (NPI 1942800172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942800172 NPI number — MADISON VLAHAKIS BOYDSTUN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYDSTUN
Provider First Name:
MADISON
Provider Middle Name:
VLAHAKIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VLAHAKIS
Provider Other First Name:
MADISON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1942800172
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1823
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71294-1823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-588-8908
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4440 VIKING DR STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-7511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-245-4113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C-80 . This is a "STATE CERTIFICATION ASSISTANT BEHAVIOR ANALYST" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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