Basic Information
| Provider Information | |||||||||
| NPI: | 1205252129 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDRIE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RSST, MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12346 BEACH ST | ||||||||
| Address2: | |||||||||
| City: | LA SALLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481459734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349156053 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 62 W 7 MILE RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482031967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138936172 | ||||||||
| FaxNumber: | 3138930064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2014 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401015444 | MI | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | 6803086484 | MI | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | 6401017135 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 6401017135 | 01 | MI | LPC | OTHER | 6803086484 | 01 | MI | REGISTERED SOCIAL SERVICE TECHNICIAN | OTHER | 6401015444 | 01 | MI | LLPC | OTHER |