Provider Demographics
NPI:1235465881
Name:BOUCHARD, BONNINE B
Entity type:Individual
Prefix:
First Name:BONNINE
Middle Name:B
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04441-0221
Mailing Address - Country:US
Mailing Address - Phone:207-695-4579
Mailing Address - Fax:
Practice Address - Street 1:2 MOOSEHEAD LAKE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:ME
Practice Address - Zip Code:04441-0221
Practice Address - Country:US
Practice Address - Phone:207-695-4579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME212406222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist