Provider Demographics
NPI:1639117880
Name:BOUDREAU, LUC G (OTR)
Entity Type:Individual
Prefix:
First Name:LUC
Middle Name:G
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 NE 14TH AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4399
Mailing Address - Country:US
Mailing Address - Phone:323-828-0618
Mailing Address - Fax:
Practice Address - Street 1:2631 NE 14TH AVE APT 203
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33334-4399
Practice Address - Country:US
Practice Address - Phone:323-828-0618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20859225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20859OtherOCCUPATIONAL THERAPY