Provider Demographics
NPI:1275075285
Name:BOLDUC, BIANCA
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 MAPLE VIEW TRL
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06759-2125
Mailing Address - Country:US
Mailing Address - Phone:203-417-5864
Mailing Address - Fax:
Practice Address - Street 1:17 COMMONS DR
Practice Address - Street 2:UNIT 6
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759
Practice Address - Country:US
Practice Address - Phone:203-417-5864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293176225100000X
CT11191225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004190328Medicaid
CT076503001Medicare PIN