Provider Demographics
NPI:1265047682
Name:BOULAIS, GENEVIEVE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:BOULAIS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 SANTA MONICA AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-4802
Mailing Address - Country:US
Mailing Address - Phone:619-560-1270
Mailing Address - Fax:619-684-3765
Practice Address - Street 1:4870 SANTA MONICA AVE STE 2B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-4802
Practice Address - Country:US
Practice Address - Phone:619-560-1270
Practice Address - Fax:619-684-3765
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP30340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP30340OtherSPEECH-LANGUAGE PATHOLOGY LICENSE