Provider Demographics
NPI:1861051310
Name:MALLETT, ALICIA FONDA
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:FONDA
Last Name:MALLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FONDA
Other - Middle Name:PRADO
Other - Last Name:MALLETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, L-SLP, CCC-SLP
Mailing Address - Street 1:1128 HIDDEN OAK LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-7123
Mailing Address - Country:US
Mailing Address - Phone:337-794-2744
Mailing Address - Fax:
Practice Address - Street 1:1128 HIDDEN OAK LN
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-7123
Practice Address - Country:US
Practice Address - Phone:337-794-2744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7029235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist