=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124090311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD BOULANGER OTR/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3911 GOLF PARK LOOP SUITE 105
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34203-3453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-756-1003
-----------------------------------------------------
Fax | 941-756-6003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3731 CHERRY ST NE
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33704-1523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-756-1003
-----------------------------------------------------
Fax | 941-756-6003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT4209
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------