Provider Demographics
NPI:1841307006
Name:BOUDREAUX, MICHELLE L (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:BOUDREAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 SOUTH BURDICK STREET
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:269-488-9691
Mailing Address - Fax:269-381-3810
Practice Address - Street 1:1131 IONIA NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-259-7900
Practice Address - Fax:269-381-3810
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010734311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97240056Medicare ID - Type Unspecified