Provider Demographics
NPI:1346436672
Name:TERI BOUDREAU, LTD.
Entity Type:Organization
Organization Name:TERI BOUDREAU, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PROFESSIONAL COUN
Authorized Official - Prefix:MS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:815-929-1940
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-0334
Mailing Address - Country:US
Mailing Address - Phone:815-929-1940
Mailing Address - Fax:
Practice Address - Street 1:310 N CONVENT ST
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2099
Practice Address - Country:US
Practice Address - Phone:815-929-1940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003442101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty