Basic Information
| Provider Information | |||||||||
| NPI: | 1790873768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDREAUX | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 LAKE AVE N | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016550002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083343817 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 01/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 9227 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 001663773 | 01 | AMERIHEALTH PPO | OTHER | 476594000 | 01 | MAGELLAN | OTHER | 7663465 | 01 | AETNA | OTHER | 3K6039 | 01 | HEALTHNET | OTHER | 42304 | 01 | UNIVERSITY HEALTHPLAN | OTHER | 2321722000 | 01 | AMERIHEALTH HMO, KEYSTONE, IBC | OTHER | 8879800 | 05 | NJ | MEDICAID |