Provider Demographics
NPI:1730116617
Name:BOUDREAUX, JOHN DANIEL (PT, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DANIEL
Last Name:BOUDREAUX
Suffix:
Gender:M
Credentials:PT, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4791
Mailing Address - Country:US
Mailing Address - Phone:337-802-5652
Mailing Address - Fax:
Practice Address - Street 1:816 HARDING ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2320
Practice Address - Country:US
Practice Address - Phone:337-232-3111
Practice Address - Fax:337-232-5400
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06867225100000X
LAJ003682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer