Provider Demographics
NPI:1417992991
Name:BOUDOURIS, RONALD (LISW)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:
Last Name:BOUDOURIS
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 W SOUTH BOUNDARY ST
Mailing Address - Street 2:STE 600
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5249
Mailing Address - Country:US
Mailing Address - Phone:419-873-8280
Mailing Address - Fax:
Practice Address - Street 1:885 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5267
Practice Address - Country:US
Practice Address - Phone:419-330-1349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH122631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBOSW05637Medicare PIN
OHBOSW05636Medicare PIN