Provider Demographics
NPI:1699332312
Name:BOUGHNER, SARA GRACE (DPT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:GRACE
Last Name:BOUGHNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4418
Mailing Address - Country:US
Mailing Address - Phone:406-926-2150
Mailing Address - Fax:406-258-0724
Practice Address - Street 1:214 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4418
Practice Address - Country:US
Practice Address - Phone:406-926-2150
Practice Address - Fax:406-258-0724
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist