Provider Demographics
NPI:1720292337
Name:BOUDREAUX, LORI ANN (MS, MED, LPC-MHSP)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:ANN
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:MS, MED, LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 WHITTLE SPRINGS ROAD
Mailing Address - Street 2:STE B
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917
Mailing Address - Country:US
Mailing Address - Phone:865-688-0661
Mailing Address - Fax:865-688-5780
Practice Address - Street 1:423 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-5641
Practice Address - Country:US
Practice Address - Phone:865-271-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YP2500X
TNLPC0000002116101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530582Medicaid