Healthcare Provider Details

I. General information

NPI: 1568993020
Provider Name (Legal Business Name): BENJAMIN ALAN BOUDREAU RADT I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44447 10TH ST W
LANCASTER CA
93534-3324
US

IV. Provider business mailing address

2225 W AVENUE K10
LANCASTER CA
93536-4602
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-2630
  • Fax:
Mailing address:
  • Phone: 805-559-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1223910316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: