Provider Demographics
NPI:1548834047
Name:BOUDREAUX, STEPHANIE KING (MED, LPC, PMH-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KING
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:MED, LPC, PMH-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1663 KEED AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-8138
Mailing Address - Country:US
Mailing Address - Phone:225-978-5713
Mailing Address - Fax:
Practice Address - Street 1:1663 KEED AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-8138
Practice Address - Country:US
Practice Address - Phone:225-978-5713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5445101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty