Provider Demographics
NPI:1053824805
Name:BOULANGER, DANIEL (ATC, CES, PES)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:BOULANGER
Suffix:
Gender:M
Credentials:ATC, CES, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-3023
Mailing Address - Country:US
Mailing Address - Phone:401-473-5733
Mailing Address - Fax:
Practice Address - Street 1:1762 LOUISQUISSET PIKE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865
Practice Address - Country:US
Practice Address - Phone:401-333-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program