Basic Information
| Provider Information | |||||||||
| NPI: | 1912213414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUDREAU | ||||||||
| FirstName: | ANN MARIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRADOSKY | ||||||||
| OtherFirstName: | ANN MARIE | ||||||||
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| OtherCredential: | PT DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4210 E BASELINE RD | ||||||||
| Address2: | 106 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805032373 | ||||||||
| FaxNumber: | 4807825213 | ||||||||
| Practice Location | |||||||||
| Address1: | 4210 E BASELINE RD | ||||||||
| Address2: | 106 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805032373 | ||||||||
| FaxNumber: | 4807825213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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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 | 9803 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 033048 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 736900 | 05 | AZ | MEDICAID |