Provider Demographics
NPI:1114901212
Name:BOULANGER, TROI ALLISON (LCSW)
Entity Type:Individual
Prefix:
First Name:TROI
Middle Name:ALLISON
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-4033
Mailing Address - Country:US
Mailing Address - Phone:978-225-2250
Mailing Address - Fax:978-225-2251
Practice Address - Street 1:836 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2861
Practice Address - Country:US
Practice Address - Phone:207-761-1160
Practice Address - Fax:207-761-1160
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC6759104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
047604OtherANTHEM BC BS
047604OtherANTHEM
LC6769OtherLICENSE