1942574132 NPI number — LACEY LAUREN BOUDREAUX PT, DPT

Table of content: LACEY LAUREN BOUDREAUX PT, DPT (NPI 1942574132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942574132 NPI number — LACEY LAUREN BOUDREAUX PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUDREAUX
Provider First Name:
LACEY
Provider Middle Name:
LAUREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1942574132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8108 PICARDY AVE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70809-3514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-819-3234
Provider Business Mailing Address Fax Number:
225-768-7919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8108 PICARDY AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-3514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-819-3234
Provider Business Practice Location Address Fax Number:
225-768-7919
Provider Enumeration Date:
03/06/2012

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: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2301985 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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