=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912213414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANN MARIE BOUDREAU PT DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2010
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24871 S ELLSWORTH RD STE 110
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-1575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-769-9753
-----------------------------------------------------
Fax | 480-769-9754
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 TUMWATER BLVD SE STE 113
-----------------------------------------------------
City | TUMWATER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98501-6422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-528-3300
-----------------------------------------------------
Fax | 360-528-8162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 033048
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 9803
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------