Basic Information
| Provider Information | |||||||||
| NPI: | 1609102714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOULANGER | ||||||||
| FirstName: | BRAD | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CREDIT UNION WAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7819611291 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 W CENTER ST | ||||||||
| Address2: | |||||||||
| City: | W BRIDGEWATER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0856594499 | ||||||||
| FaxNumber: | 5085104987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2009 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 18835 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.