=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457488959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONSTANTINA HELEN BOUDOUVAS MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 DAIRY ASHFORD ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77079-5310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-264-8968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10414 GOLD POINT DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77064-7106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-264-8968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 36098
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------