Provider Demographics
NPI:1760019913
Name:BOUDREAUX, CHANICE UNCHELLE (MMT, RP, LMT)
Entity Type:Individual
Prefix:
First Name:CHANICE
Middle Name:UNCHELLE
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:MMT, RP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8733 SIEGEN LN # 401
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-1945
Mailing Address - Country:US
Mailing Address - Phone:225-428-6614
Mailing Address - Fax:225-256-0490
Practice Address - Street 1:4303 PLANK RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805-4134
Practice Address - Country:US
Practice Address - Phone:225-428-6614
Practice Address - Fax:225-256-0490
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA9008225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1760019913OtherVETERANS DEPT