Provider Demographics
NPI:1912213414
Name:BOUDREAU, ANN MARIE (PT DPT)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:ANN MARIE
Other - Middle Name:
Other - Last Name:BRADOSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT DPT
Mailing Address - Street 1:4210 E BASELINE RD
Mailing Address - Street 2:106
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4417
Mailing Address - Country:US
Mailing Address - Phone:480-503-2373
Mailing Address - Fax:480-782-5213
Practice Address - Street 1:4210 E BASELINE RD
Practice Address - Street 2:106
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4417
Practice Address - Country:US
Practice Address - Phone:480-503-2373
Practice Address - Fax:480-782-5213
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9803225100000X
NY033048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ736900Medicaid
AZ736900Medicaid
NY1912213414Medicare PIN