=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346436672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERI BOUDREAU, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 12/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 N CONVENT ST
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-2099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-929-1940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 334
-----------------------------------------------------
City | BRADLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60915-0334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-929-1940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PROFESSIONAL COUN
-----------------------------------------------------
Name | MS. TERI DEAN BOUDREAU
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 815-929-1940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180003442
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------