Healthcare Provider Details

I. General information

NPI: 1578992376
Provider Name (Legal Business Name): TAILYR MARNAE BOUDREAUX MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 N 1ST AVE
PHOENIX AZ
85003-1513
US

IV. Provider business mailing address

380 N 1ST AVE
PHOENIX AZ
85003-1513
US

V. Phone/Fax

Practice location:
  • Phone: 661-406-8553
  • Fax:
Mailing address:
  • Phone: 661-406-8553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number26304
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7306
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14560
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: