Provider Demographics
NPI:1609102714
Name:BOULANGER, BRAD (DPT)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BOULANGER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:711 W CENTER ST
Practice Address - Street 2:
Practice Address - City:W BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379
Practice Address - Country:US
Practice Address - Phone:085-659-4499
Practice Address - Fax:508-510-4987
Is Sole Proprietor?:No
Enumeration Date:2009-10-23
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist