Basic Information
| Provider Information | |||||||||
| NPI: | 1285698159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDREAUX | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MSW LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9102 CHEYENNE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134163133 | ||||||||
| FaxNumber: | 3134163133 | ||||||||
| Practice Location | |||||||||
| Address1: | 33101 ANNAPOLIS ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | WAYNE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481842405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347210200 | ||||||||
| FaxNumber: | 7347211766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801079489 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.