Provider Demographics
NPI:1356817829
Name:BOUDREAU, RACHEL (LMSW)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12212 OLD GLENN HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12212 OLD GLENN HWY STE 1
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7319
Practice Address - Country:US
Practice Address - Phone:907-696-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK135825104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK135825OtherLICENSED MASTER SOCIAL WORKER