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General NPI Number Information
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NPI Number | 1225437866
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Entity Type | Individual
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Provider Name | RYAN JACOB BOUDREAUX PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 08/20/2014
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Last Update Date | 03/11/2025
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Provider Practice Location Address
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Address Line | 1725 W HARRISON ST STE 440
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City | CHICAGO
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State | IL
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Zip | 60612-3836
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Country | US
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Telephone | 312-563-2454
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Fax |
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Provider Business Mailing Address
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Address Line | 1725 W HARRISON ST STE 440
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City | CHICAGO
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State | IL
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Zip | 60612-3836
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Country | US
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Telephone | 312-563-2454
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251N0400X
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Taxonomy Name | Neurology Physical Therapist
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License Number | PT011641
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 2251N0400X
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Taxonomy Name | Neurology Physical Therapist
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License Number | 070021877
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License Number State | IL
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