Provider Demographics
NPI:1215468921
Name:BOUDREAUX, MICHELLE CATHERINE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CATHERINE
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 VIA LIDO # 310
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3908
Mailing Address - Country:US
Mailing Address - Phone:949-723-2388
Mailing Address - Fax:949-723-1288
Practice Address - Street 1:1601 W BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4527
Practice Address - Country:US
Practice Address - Phone:949-723-2388
Practice Address - Fax:949-723-1288
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300144AP101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)