Provider Demographics
NPI:1972273084
Name:BOULDIN, JANINE RENE (LSW)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:RENE
Last Name:BOULDIN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 HIGH ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5830
Mailing Address - Country:US
Mailing Address - Phone:440-477-7191
Mailing Address - Fax:
Practice Address - Street 1:8445 MUNSON RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-2410
Practice Address - Country:US
Practice Address - Phone:440-255-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 171M00000X
OHS.2208539104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator