Provider Demographics
NPI:1285698159
Name:BOUDREAUX, BRENDA A (MSW LMSW)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:A
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:MSW LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9102 CHEYENNE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228
Mailing Address - Country:US
Mailing Address - Phone:313-416-3133
Mailing Address - Fax:313-416-3133
Practice Address - Street 1:33101 ANNAPOLIS ST
Practice Address - Street 2:SUITE B
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-721-0200
Practice Address - Fax:734-721-1766
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801079489104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker