Provider Demographics
NPI:1912408253
Name:BAULDRY, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:BAULDRY
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 1:610 MCKINLEY CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-6688
Mailing Address - Country:US
Mailing Address - Phone:734-673-7827
Mailing Address - Fax:
Practice Address - Street 1:33000 ANNAPOLIS ST STE 210
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2920
Practice Address - Country:US
Practice Address - Phone:734-467-4134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004860225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation