Provider Demographics
NPI:1780911982
Name:BOUCHARD, ANN MARIE
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
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 1:6165 E BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1738
Mailing Address - Country:US
Mailing Address - Phone:517-983-2253
Mailing Address - Fax:810-695-0888
Practice Address - Street 1:6165 E BRISTOL RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1738
Practice Address - Country:US
Practice Address - Phone:517-983-2253
Practice Address - Fax:810-695-0888
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist