Provider Demographics
NPI:1447280383
Name:BOUDOURIS, GEORGE (PSYD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:BOUDOURIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5243 PARK RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3162
Mailing Address - Country:US
Mailing Address - Phone:434-825-4878
Mailing Address - Fax:
Practice Address - Street 1:5243 PARK RIDGE CT
Practice Address - Street 2:
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-3162
Practice Address - Country:US
Practice Address - Phone:434-825-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810002895103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA345410000OtherMAGELLAN
VA7704925Medicaid
VA084692OtherOPTIMA
VA472808OtherVALUE OPTIONS
VA7685432OtherAETNA
VA435591OtherANTHEM
VAS28172Medicare UPIN
VA680001450Medicare ID - Type Unspecified