Provider Demographics
NPI:1134298300
Name:BOURBONNIERE, MELISSA CHRISTINA (OTRL)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHRISTINA
Last Name:BOURBONNIERE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 NOEL DR
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3348
Mailing Address - Country:US
Mailing Address - Phone:650-353-0953
Mailing Address - Fax:
Practice Address - Street 1:1899 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-6130
Practice Address - Country:US
Practice Address - Phone:650-326-9080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 8161225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist