Provider Demographics
NPI:1144886581
Name:BOUDREAU, REBECCA MARIE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MARIE
Other - Last Name:GRAEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8609 W BRYN MAWR AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3524
Mailing Address - Country:US
Mailing Address - Phone:773-644-7787
Mailing Address - Fax:
Practice Address - Street 1:1823 S NEIL ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7272
Practice Address - Country:US
Practice Address - Phone:224-298-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-22-58068103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst