Provider Demographics
NPI:1417676263
Name:GOUDREAULT, EMILY IRENE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:IRENE
Last Name:GOUDREAULT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:IRENE
Other - Last Name:FOLSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5904 PRESERVATION DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419-9693
Mailing Address - Country:US
Mailing Address - Phone:970-988-6718
Mailing Address - Fax:
Practice Address - Street 1:291 W LAKEWOOD BLVD STE H
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-1969
Practice Address - Country:US
Practice Address - Phone:970-988-6718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005049235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist