Provider Demographics
NPI:1770603862
Name:BOULLARD, KIMBERLY DIANE (OTR)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DIANE
Last Name:BOULLARD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DIANE
Other - Last Name:BACKUNAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:9-1 TUCK FARM RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2455
Mailing Address - Country:US
Mailing Address - Phone:508-832-8041
Mailing Address - Fax:
Practice Address - Street 1:1000 EDDY STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-533-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT 01140225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI640014OtherUNITED
RI99947OtherBCROSS
RI2058OtherNHPRC