Provider Demographics
NPI:1508406380
Name:BOUDREAU, JUSTINE RAE (BCBA)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:RAE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 N ELSTON AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1501
Mailing Address - Country:US
Mailing Address - Phone:248-762-5293
Mailing Address - Fax:
Practice Address - Street 1:1765 N ELSTON AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1501
Practice Address - Country:US
Practice Address - Phone:248-762-5293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-19-38906103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty