Basic Information
| Provider Information | |||||||||
| NPI: | 1356971345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENDREAU | ||||||||
| FirstName: | LINDSAY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORAN | ||||||||
| OtherFirstName: | LINDSAY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | BCBA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 625 WOOD ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028092424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194065855 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 PLEASANT ST STE 130 | ||||||||
| Address2: | |||||||||
| City: | NEW BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027406254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669264345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2020 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 2936 | MA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.