Healthcare Provider Details

I. General information

NPI: 1255192480
Provider Name (Legal Business Name): CONNOR BOUDREAU DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 US 301 N
ELLENTON FL
34222-2008
US

IV. Provider business mailing address

PO BOX 632649
CINCINNATI OH
45263-2649
US

V. Phone/Fax

Practice location:
  • Phone: 941-344-9238
  • Fax:
Mailing address:
  • Phone: 941-344-9238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT43034
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: