=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508103102
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHARON DUGAS BOUDREAUX BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2013
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 E PRESIDENT AVE
-----------------------------------------------------
City | TUPELO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38801-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-205-4375
-----------------------------------------------------
Fax | 662-584-2990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 924 LAKE DR
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38843-8936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-254-1688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-12-12034
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------