Active NPI
Edwin D Boudreaux, PH.D.
- Clinical Psychologist
- Worcester, MA
National Provider Identifier
1790873768
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 9227
- Practice address
- 55 Lake Ave N
Worcester, MA 01655-0002 - Phone
- (508) 334-3817
- NPI assigned
- Oct 11, 2006
- Last updated
- Jan 25, 2017
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 9227 | MA | Primary |
Addresses
Primary practice location
55 Lake Ave N
Worcester, MA 01655-0002
Mailing address
PO Box 415348
Boston, MA 02241-5348
Phone (800) 225-8885
Other identifiers 7
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 7663465 | Other | AETNA | |
| 3K6039 | Other | HEALTHNET | |
| 001663773 | Other | AMERIHEALTH PPO | |
| 8879800 | Medicaid | NJ | |
| 476594000 | Other | MAGELLAN | |
| 2321722000 | Other | AMERIHEALTH HMO, KEYSTONE, IBC | |
| 42304 | Other | UNIVERSITY HEALTHPLAN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 9227 | MA | MD | Orthodontics and Dentofacial Orthopedic Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1160524800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1485302400000",
"number": "1790873768",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 415348",
"city": "BOSTON",
"state": "MA",
"postal_code": "022415348",
"telephone_number": "800-225-8885",
"fax_number": "508-334-1977"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "55 LAKE AVE N",
"city": "WORCESTER",
"state": "MA",
"postal_code": "016550002",
"telephone_number": "508-334-3817"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUDREAUX",
"first_name": "EDWIN",
"middle_name": "D",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-10-11",
"last_updated": "2017-01-25",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "MA",
"license": "9227",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA",
"identifier": "7663465",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HEALTHNET",
"identifier": "3K6039",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AMERIHEALTH PPO",
"identifier": "001663773",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "8879800",
"state": "NJ"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MAGELLAN",
"identifier": "476594000",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AMERIHEALTH HMO, KEYSTONE, IBC",
"identifier": "2321722000",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNIVERSITY HEALTHPLAN",
"identifier": "42304",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Worcester, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 25, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.