Provider Demographics
NPI:1205252129
Name:BOUDRIE, TRACY L (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:L
Last Name:BOUDRIE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12346 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:MI
Mailing Address - Zip Code:48145-9734
Mailing Address - Country:US
Mailing Address - Phone:734-915-6053
Mailing Address - Fax:
Practice Address - Street 1:11521 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3050
Practice Address - Country:US
Practice Address - Phone:313-733-4256
Practice Address - Fax:313-733-4265
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017135101YP2500X, 101YP2500X
MI6803086484171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401017135OtherLPC
MI6401015444OtherLLPC
MI6803086484OtherREGISTERED SOCIAL SERVICE TECHNICIAN