Provider Demographics
NPI:1992045348
Name:BOUDREAUX, LYDIA R (PT, SIPT CERT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:R
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:PT, SIPT CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12840 HILLCREST RD
Mailing Address - Street 2:SUITE E104
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-1528
Mailing Address - Country:US
Mailing Address - Phone:972-608-0909
Mailing Address - Fax:
Practice Address - Street 1:12840 HILLCREST RD
Practice Address - Street 2:SUITE E104
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-1528
Practice Address - Country:US
Practice Address - Phone:972-608-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1062743225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist