Provider Demographics
NPI:1306274584
Name:BOULANGER, BRIANNA LEIGH (MT)
Entity type:Individual
Prefix:MS
First Name:BRIANNA
Middle Name:LEIGH
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HIGHLAND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-305-5280
Practice Address - Fax:401-305-5285
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01910225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist