Healthcare Provider Details

I. General information

NPI: 1124194048
Provider Name (Legal Business Name): STEPHANIE LYNN BOUDREAU DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

71 NATHAN LANE
PLYMOUTH MA
02360
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5301
  • Fax:
Mailing address:
  • Phone: 508-265-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16343
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: