Provider Demographics
NPI:1275506768
Name:LADOUCEUR, ANDREA L (DPT)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:L
Last Name:LADOUCEUR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 N GAIL PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2056
Mailing Address - Country:US
Mailing Address - Phone:218-779-5570
Mailing Address - Fax:
Practice Address - Street 1:5255 OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2637
Practice Address - Country:US
Practice Address - Phone:208-338-9486
Practice Address - Fax:208-338-9586
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTD389OtherBLUE CROSS
ID000010153394OtherBLUE SHIELD
ID000010153394OtherBLUE SHIELD