Provider Demographics
NPI:1447790746
Name:BOUDREAU, NICOLE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BERNICE AVE
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-1771
Mailing Address - Country:US
Mailing Address - Phone:978-413-0179
Mailing Address - Fax:
Practice Address - Street 1:55 BERNICE AVE
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-1771
Practice Address - Country:US
Practice Address - Phone:978-413-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12233225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist