Provider Demographics
NPI:1609860436
Name:BOUDRIE, MICHAEL EDWARD (CSW LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:BOUDRIE
Suffix:
Gender:M
Credentials:CSW LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4328 COUSINO
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:MI
Mailing Address - Zip Code:48145-9623
Mailing Address - Country:US
Mailing Address - Phone:734-457-3426
Mailing Address - Fax:734-457-3426
Practice Address - Street 1:2092 S CUSTER RD
Practice Address - Street 2:CARING ALTERNATIVES
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1831
Practice Address - Country:US
Practice Address - Phone:734-242-8711
Practice Address - Fax:734-242-3955
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001543103TC1900X
MI6801035097104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
08312005386318OtherBSBC