Provider Demographics
NPI:1497150437
Name:BOUCHER, MELISSA NICOLE (MS, OTR/L)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:NICOLE
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 COACHMANS WHIP
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9600
Mailing Address - Country:US
Mailing Address - Phone:315-391-1809
Mailing Address - Fax:
Practice Address - Street 1:105 CONVENTION DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4595
Practice Address - Country:US
Practice Address - Phone:919-234-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11456225X00000X
NY019085225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist