Provider Demographics
NPI:1669650172
Name:BOUDOUSQUIE, BRUCE GREGORY (LPC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GREGORY
Last Name:BOUDOUSQUIE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BASS LN
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:ID
Mailing Address - Zip Code:83836-9689
Mailing Address - Country:US
Mailing Address - Phone:208-920-0666
Mailing Address - Fax:
Practice Address - Street 1:43 BASS LN
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:ID
Practice Address - Zip Code:83836-9689
Practice Address - Country:US
Practice Address - Phone:208-920-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC3283101Y00000X
MTLCPC-2241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional