Provider Demographics
NPI:1164933396
Name:BOUCHARD, MELISSA BETH
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:BETH
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 1:32411 BRIARCREST KNLS
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1515
Mailing Address - Country:US
Mailing Address - Phone:917-575-0823
Mailing Address - Fax:
Practice Address - Street 1:32411 BRIARCREST KNLS
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1515
Practice Address - Country:US
Practice Address - Phone:917-575-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 175T00000X
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer Specialist
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty