Provider Demographics
NPI:1992714893
Name:BOUDREAU, STEPAHNIE CHRISTINE
Entity type:Individual
Prefix:
First Name:STEPAHNIE
Middle Name:CHRISTINE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:CHRISTINE
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 64277
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4277
Mailing Address - Country:US
Mailing Address - Phone:410-328-7037
Mailing Address - Fax:410-328-3311
Practice Address - Street 1:611 S CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3801
Practice Address - Country:US
Practice Address - Phone:410-328-2293
Practice Address - Fax:410-328-5895
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD121171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ096Medicare ID - Type Unspecified