Healthcare Provider Details

I. General information

NPI: 1194629592
Provider Name (Legal Business Name): CLIFTON BOUDREAUX JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11616 SOUTHFORK AVE STE 403
BATON ROUGE LA
70816-5241
US

IV. Provider business mailing address

1206 GREEN KNOLL DR
SUGAR LAND TX
77479-6005
US

V. Phone/Fax

Practice location:
  • Phone: 225-261-7143
  • Fax:
Mailing address:
  • Phone: 832-628-1074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number18655
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: