Provider Demographics
NPI:1386657914
Name:BOUCHER-SNODGRASS, MICHELLE DENISE (PHD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DENISE
Last Name:BOUCHER-SNODGRASS
Suffix:
Gender:F
Credentials:PHD
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 8068
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39303-8068
Mailing Address - Country:US
Mailing Address - Phone:601-693-8307
Mailing Address - Fax:601-693-6794
Practice Address - Street 1:5004 HIGHWAY 39 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1021
Practice Address - Country:US
Practice Address - Phone:601-693-8307
Practice Address - Fax:601-639-6794
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS45-732103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07170249Medicaid
MSQ53168Medicare UPIN
MS680000281Medicare ID - Type Unspecified