Provider Demographics
NPI:1942574132
Name:BOUDREAUX, LACEY LAUREN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:LAUREN
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8108 PICARDY AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3514
Mailing Address - Country:US
Mailing Address - Phone:225-819-3234
Mailing Address - Fax:225-768-7919
Practice Address - Street 1:8108 PICARDY AVE
Practice Address - Street 2:SUITE D
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3514
Practice Address - Country:US
Practice Address - Phone:225-819-3234
Practice Address - Fax:225-768-7919
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2301985Medicaid