Basic Information
| Provider Information | |||||||||
| NPI: | 1710050778 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUCHEREAU | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MPTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 138 SW 96TH AVE | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333242357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544767182 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 OAKWOOD BLVD STE 130 | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330201937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549253844 | ||||||||
| FaxNumber: | 9549253845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 09/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT19446 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 886421700 | 05 | FL | MEDICAID |