Provider Demographics
NPI:1093753741
Name:BOULWARE, LAURIE LAYTON (PT, DPT, CSCS)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:LAYTON
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 SAN JOAQUIN HILLS RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-6507
Mailing Address - Country:US
Mailing Address - Phone:949-721-9400
Mailing Address - Fax:
Practice Address - Street 1:26921 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6501
Practice Address - Country:US
Practice Address - Phone:949-582-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 28645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 28645OtherPT LICENSE