Provider Demographics
NPI:1982890265
Name:BOUCHEREAU, MYRNA C (LPT)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:C
Last Name:BOUCHEREAU
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5254 TRENTS PL
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1333
Mailing Address - Country:US
Mailing Address - Phone:225-753-0503
Mailing Address - Fax:
Practice Address - Street 1:5254 TRENTS PL
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1333
Practice Address - Country:US
Practice Address - Phone:225-753-0503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT032R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist