MEDICARE: GENEVIEVE BOULAIS MA CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP30340	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SP30340	OTHER	CA	SPEECH-LANGUAGE PATHOLOGY LICENSE

General Provider Information

NPI Number	:	1265047682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GENEVIEVE BOULAIS MA CCC-SLP

Provider Business Mailing Address
First Line	:	4870 SANTA MONICA AVE STE 2B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-4802
Country	:	US
Telephone Number	:	619-560-1270
Fax Number	:	619-684-3765

Provider Business Practice Location Address
First Line	:	4870 SANTA MONICA AVE STE 2B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-4802
Country	:	US
Telephone Number	:	619-560-1270
Fax Number	:	619-684-3765

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2020
Last Update Date	:	09/11/2020

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