Basic Information
| Provider Information | |||||||||
| NPI: | 1669006730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDREAUX | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ST. CHARLES | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | CALLER BOX C-268 | ||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL RD | ||||||||
| Address2: | CALLER BOX C-268 | ||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287192871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2020 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P013735 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.