Basic Information
| Provider Information | |||||||||
| NPI: | 1609860436 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDRIE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CSW LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4328 COUSINO | ||||||||
| Address2: | |||||||||
| City: | LA SALLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481459623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344573426 | ||||||||
| FaxNumber: | 7344573426 | ||||||||
| Practice Location | |||||||||
| Address1: | 2092 S CUSTER RD | ||||||||
| Address2: | CARING ALTERNATIVES | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481611831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342428711 | ||||||||
| FaxNumber: | 7342423955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 6401001543 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 104100000X | 6801035097 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 08312005386318 | 01 | BSBC | OTHER |