MEDICARE: ALLYCYN BOUDREAU MOT, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	334365	CA
2	225X00000X	Occupational Therapist	7531	SC

General Provider Information

NPI Number	:	1184504557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLYCYN BOUDREAU MOT, OTR/L

Provider Business Mailing Address
First Line	:	1127 QUEENSBOROUGH BLVD STE 104
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-5431
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 QUEENSBOROUGH BLVD STE 104
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-5431
Country	:	US
Telephone Number	:	843-216-0299
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2025
Last Update Date	:	12/12/2025

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Directions to “ ALLYCYN BOUDREAU MOT, OTR/L” Practice Location

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