Provider Demographics
NPI:1174647432
Name:BOUDREAUX, CHARLES ANTHONY JR
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ANTHONY
Last Name:BOUDREAUX
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 REMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2865
Mailing Address - Country:US
Mailing Address - Phone:601-949-1949
Mailing Address - Fax:601-714-6922
Practice Address - Street 1:431 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-1108
Practice Address - Country:US
Practice Address - Phone:601-949-1949
Practice Address - Fax:601-714-6922
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0980101YP2500X
MST0023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist