Provider Demographics
NPI:1548714397
Name:BOULOS, NATHALIE (MD)
Entity type:Individual
Prefix:
First Name:NATHALIE
Middle Name:
Last Name:BOULOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LONDONDERRY DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7915
Mailing Address - Country:US
Mailing Address - Phone:254-751-4880
Mailing Address - Fax:
Practice Address - Street 1:301 LONDONDERRY DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7915
Practice Address - Country:US
Practice Address - Phone:254-751-4880
Practice Address - Fax:254-751-4885
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190245392084P0800X
TXS92702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry