Provider Demographics
NPI:1568993020
Name:BOUDREAU, BENJAMIN ALAN (RADT I)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:ALAN
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:RADT I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 W AVENUE K10
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-4602
Mailing Address - Country:US
Mailing Address - Phone:805-559-3502
Mailing Address - Fax:
Practice Address - Street 1:44447 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3324
Practice Address - Country:US
Practice Address - Phone:661-726-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1223910316101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1447791389Medicaid
CA1447791389Medicare NSC