Provider Demographics
NPI:1629211388
Name:BOUDREAU, KRISTEN LEIGH (PCC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3342
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-0161
Mailing Address - Country:US
Mailing Address - Phone:614-477-4390
Mailing Address - Fax:
Practice Address - Street 1:10330 SAWMILL PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-7790
Practice Address - Country:US
Practice Address - Phone:614-477-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.0701103101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional