Provider Demographics
NPI:1184154833
Name:BOUDREAU, DAWN MARIE (PTA)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01833-1829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 MORRILL ST
Practice Address - Street 2:
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913-3012
Practice Address - Country:US
Practice Address - Phone:978-388-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA961225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicaid