Provider Demographics
NPI:1689804114
Name:BOULAC, SARAH L (MA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:L
Last Name:BOULAC
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N 18TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3413
Mailing Address - Country:US
Mailing Address - Phone:765-423-5361
Mailing Address - Fax:765-447-8411
Practice Address - Street 1:615 N 18TH ST STE 101
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3413
Practice Address - Country:US
Practice Address - Phone:765-423-5361
Practice Address - Fax:765-447-8411
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003518A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health