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General NPI Number Information
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NPI Number | 1053837443
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Entity Type | Individual
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Provider Name | NIKULAS LAGENE BOUDREAUX
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Gender | Male
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Dates
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Enumeration Date | 08/17/2017
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Last Update Date | 06/24/2023
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Provider Practice Location Address
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Address Line | 755 W HAMBURG ST
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City | BALTIMORE
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State | MD
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Zip | 21230-2540
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Country | US
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Telephone | 915-490-0002
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Fax |
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Provider Business Mailing Address
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Address Line | 3612 N CHOUTEAU TRFY APT B
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City | KANSAS CITY
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State | MO
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Zip | 64117-3106
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 08092017273360
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 10341
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License Number State | KS
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