Provider Demographics
NPI:1114179108
Name:BOULET, JEAN GUILLAUME NICOLAS (LCSW)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:GUILLAUME NICOLAS
Last Name:BOULET
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:BOULET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2709 PINEDALE RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-2018
Mailing Address - Country:US
Mailing Address - Phone:336-223-5521
Mailing Address - Fax:336-288-3177
Practice Address - Street 1:2709 PINEDALE RD STE B
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-2018
Practice Address - Country:US
Practice Address - Phone:336-223-5521
Practice Address - Fax:336-288-3177
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0082971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC18859OtherBCBS
NC1114179108OtherUBH
NC1114179108OtherHUMANA
NCMAGELLANOther601112-311
NC1114179108OtherUBH