Provider Demographics
NPI:1003150335
Name:BOUDREAU, ALICE
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:BOUDREAU
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 1:860 STEELE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-3945
Mailing Address - Country:US
Mailing Address - Phone:303-236-5945
Mailing Address - Fax:303-236-6072
Practice Address - Street 1:860 STEELE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-3945
Practice Address - Country:US
Practice Address - Phone:303-236-5945
Practice Address - Fax:303-236-6072
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO352092083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine