Provider Demographics
NPI:1811664899
Name:BOLDUC, BRENDAN RAYMOND (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:RAYMOND
Last Name:BOLDUC
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5914
Mailing Address - Country:US
Mailing Address - Phone:201-488-0488
Mailing Address - Fax:
Practice Address - Street 1:15 S KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-2112
Practice Address - Country:US
Practice Address - Phone:201-573-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02024200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist