Healthcare Provider Details

I. General information

NPI: 1619657806
Provider Name (Legal Business Name): MAVE OPAL BERGERON MED, BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 JAMES COMEAUX RD STE B
LAFAYETTE LA
70508-3376
US

IV. Provider business mailing address

328 S 2ND ST
IOTA LA
70543-6051
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone: 337-305-6930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberL747
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: