Provider Demographics
NPI:1083590376
Name:BOULANGER, PATRICK KING (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:KING
Last Name:BOULANGER
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15630 PINEHURST DR STE 1
Mailing Address - Street 2:
Mailing Address - City:BASEHOR
Mailing Address - State:KS
Mailing Address - Zip Code:66007-8238
Mailing Address - Country:US
Mailing Address - Phone:913-728-2065
Mailing Address - Fax:
Practice Address - Street 1:15630 PINEHURST DR STE 1
Practice Address - Street 2:
Practice Address - City:BASEHOR
Practice Address - State:KS
Practice Address - Zip Code:66007-8238
Practice Address - Country:US
Practice Address - Phone:913-728-2065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-04497225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist