Provider Demographics
NPI:1861371965
Name:BOULICAULT, SAVANNAH KATHERINE
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:KATHERINE
Last Name:BOULICAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 RIVERVIEW MANOR DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-6141
Mailing Address - Country:US
Mailing Address - Phone:314-401-4955
Mailing Address - Fax:
Practice Address - Street 1:323 PAUL W BRYANT DR
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2094
Practice Address - Country:US
Practice Address - Phone:314-401-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program