Healthcare Provider Details

I. General information

NPI: 1841307006
Provider Name (Legal Business Name): MICHELLE L BOUDREAUX LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE L BOUDREAUX

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 IONIA NW
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

610 SOUTH BURDICK STREET
KALAMAZOO MI
49007
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-7900
  • Fax: 269-381-3810
Mailing address:
  • Phone: 269-488-9691
  • Fax: 269-381-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801073431
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: