Provider Demographics
NPI:1013222850
Name:BOULETTE, DONNA MERLE (SLP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MERLE
Last Name:BOULETTE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3944
Mailing Address - Country:US
Mailing Address - Phone:325-315-3146
Mailing Address - Fax:
Practice Address - Street 1:1950 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3944
Practice Address - Country:US
Practice Address - Phone:325-315-3146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80195231H00000X
TX103968235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist