Basic Information
| Provider Information | |||||||||
| NPI: | 1558536342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDREAUX | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.A., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1748 E HERMITAGE ST | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707374914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257153753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 CHARLEVOIX DR SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495467085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003258064 | ||||||||
| FaxNumber: | 8003251326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 04/23/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 05663 | MD | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 5657 | LA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.