Provider Demographics
NPI:1043395007
Name:BOUDREAU, EDWARD J (PT, OCS)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3537
Mailing Address - Country:US
Mailing Address - Phone:978-766-0880
Mailing Address - Fax:
Practice Address - Street 1:16 HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-7929
Practice Address - Country:US
Practice Address - Phone:781-372-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA331772251X0800X
MA151102251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic