Provider Demographics
NPI:1710050778
Name:BOUCHEREAU, ANNIE (MPTA)
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:
Last Name:BOUCHEREAU
Suffix:
Gender:F
Credentials:MPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 SW 96TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2357
Mailing Address - Country:US
Mailing Address - Phone:954-476-7182
Mailing Address - Fax:
Practice Address - Street 1:1 OAKWOOD BLVD STE 130
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1937
Practice Address - Country:US
Practice Address - Phone:954-925-3844
Practice Address - Fax:954-925-3845
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT19446225100000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886421700Medicaid
FLY075FZMedicare ID - Type Unspecified