Provider Demographics
NPI:1629475199
Name:BOUEY, RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:
Last Name:BOUEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18480 LANCASHIRE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18480 LANCASHIRE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1325
Practice Address - Country:US
Practice Address - Phone:313-272-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-29
Last Update Date:2014-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002743103TC0700X
MICC-0C1790525433103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical