Provider Demographics
NPI:1710642020
Name:BOUDJALIS, CHLOE
Entity Type:Individual
Prefix:
First Name:CHLOE
Middle Name:
Last Name:BOUDJALIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 LAKEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-9053
Mailing Address - Country:US
Mailing Address - Phone:231-409-6311
Mailing Address - Fax:
Practice Address - Street 1:1810 CHARTWELL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-9283
Practice Address - Country:US
Practice Address - Phone:231-929-2354
Practice Address - Fax:231-929-2853
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician