Healthcare Provider Details

I. General information

NPI: 1487435442
Provider Name (Legal Business Name): RYAN EARL BOUDREAUX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 4TH AVE STE 215
LAKE CHARLES LA
70601-7887
US

IV. Provider business mailing address

500 BROAD ST # 213
LAKE CHARLES LA
70601-4335
US

V. Phone/Fax

Practice location:
  • Phone: 337-707-3872
  • Fax:
Mailing address:
  • Phone: 337-707-3872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLC10351
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: