Provider Demographics
NPI:1417669763
Name:BOUDREAUX, JOHN DALTON (MA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DALTON
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 ENTERPRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-6371
Mailing Address - Country:US
Mailing Address - Phone:337-429-5129
Mailing Address - Fax:337-214-2077
Practice Address - Street 1:1925 ENTERPRISE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-6371
Practice Address - Country:US
Practice Address - Phone:337-429-5129
Practice Address - Fax:337-214-2077
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8871101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional