MEDICARE: LISA JO BOUDRIEAU PT

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	225100000X	Physical Therapist	3604	KS

General Provider Information

NPI Number	:	1720095995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JO BOUDRIEAU PT

Provider Business Mailing Address
First Line	:	4629 W 72ND TER
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208-2827
Country	:	US
Telephone Number	:	913-831-6242
Fax Number	:

Provider Business Practice Location Address
First Line	:	12000 W 110TH ST
Second Line	:	SUITE 400
City	:	OVERLAND PARK
State	:	KS
Zip	:	66210-3938
Country	:	US
Telephone Number	:	816-679-7056
Fax Number	:	816-523-0306

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	07/08/2007

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