Provider Demographics
NPI:1912213414
Name:BOUDREAU, ANN MARIE (PT DPT)
Entity type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:
Credentials:PT DPT
Other - Prefix:
Other - First Name:ANN MARIE
Other - Middle Name:
Other - Last Name:BRADOSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT DPT
Mailing Address - Street 1:111 TUMWATER BLVD SE STE 113
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-6422
Mailing Address - Country:US
Mailing Address - Phone:360-528-3300
Mailing Address - Fax:360-528-8162
Practice Address - Street 1:24871 S ELLSWORTH RD STE 110
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-1575
Practice Address - Country:US
Practice Address - Phone:480-769-9753
Practice Address - Fax:480-769-9754
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033048225100000X
AZ9803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ736900Medicaid
AZ736900Medicaid
NY1912213414Medicare PIN