1568782068 NPI number — DR. DIANE MARIE BOUDREAUX PHD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568782068 NPI number — DR. DIANE MARIE BOUDREAUX PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUDREAUX
Provider First Name:
DIANE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568782068
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 HERMANN MUSEUM CIRCLE DR APT 5108
Provider Second Line Business Mailing Address:
INTEGRATED BEHAVIORAL HEALTH&WELLNESS CONSULTANTS,PLLC
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77004-7970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-997-7001
Provider Business Mailing Address Fax Number:
888-870-6542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2646 S LOOP W
Provider Second Line Business Practice Location Address:
SUITE 180D
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77054-2665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-997-7001
Provider Business Practice Location Address Fax Number:
888-870-6542
Provider Enumeration Date:
06/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  35073 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3259929 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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