=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861913998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLENE BOUDREAU RADT1
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2017
-----------------------------------------------------
Last Update Date | 01/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2844 COLOMA ST
-----------------------------------------------------
City | PLACERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95667-4406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-333-9460
-----------------------------------------------------
Fax | 530-333-1019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 871
-----------------------------------------------------
City | GARDEN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95633-0871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-333-9460
-----------------------------------------------------
Fax | 530-333-1019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | R1241720117
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | RH0007941221
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------