Provider Demographics
NPI:1992936132
Name:BOUDREAUX, CINDY JEAN (COTA/L)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:JEAN
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12094
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2094
Mailing Address - Country:US
Mailing Address - Phone:706-589-3773
Mailing Address - Fax:
Practice Address - Street 1:707 STANTON DR
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3264
Practice Address - Country:US
Practice Address - Phone:706-589-3773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC763224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC763OtherCOTA/L LICENSE OF SC