Provider Demographics
NPI:1396841490
Name:BOUDREAUX, DARLENE S (OTR)
Entity Type:Individual
Prefix:MS
First Name:DARLENE
Middle Name:S
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:DARLENE
Other - Middle Name:S
Other - Last Name:ST JOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:897 SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:BEEBE
Mailing Address - State:AR
Mailing Address - Zip Code:72012-9897
Mailing Address - Country:US
Mailing Address - Phone:501-288-1199
Mailing Address - Fax:501-882-3179
Practice Address - Street 1:1811 W DEWITT HENRY DR
Practice Address - Street 2:
Practice Address - City:BEEBE
Practice Address - State:AR
Practice Address - Zip Code:72012-2026
Practice Address - Country:US
Practice Address - Phone:501-288-1199
Practice Address - Fax:501-882-3179
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR751225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y177OtherBLUE CROSS BLUE SHIELD
AR155469721Medicaid
5Y177Medicare ID - Type Unspecified