Provider Demographics
NPI:1255688891
Name:BOUDREAU, CHRISTINE L (LMT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:L
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1672
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-1672
Mailing Address - Country:US
Mailing Address - Phone:207-632-7044
Mailing Address - Fax:
Practice Address - Street 1:836 MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2861
Practice Address - Country:US
Practice Address - Phone:207-632-7044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT1175172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist