Provider Demographics
NPI:1164804423
Name:BOULT, JOHANNA (PHD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:BOULT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:WEDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2970
Mailing Address - Fax:318-813-2981
Practice Address - Street 1:1450 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4204
Practice Address - Country:US
Practice Address - Phone:318-813-2970
Practice Address - Fax:318-813-2981
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4477235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174173Medicaid