Provider Demographics
NPI:1528203916
Name:BOUCHARD-NICHOLS, MARLIS YVONNE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MARLIS
Middle Name:YVONNE
Last Name:BOUCHARD-NICHOLS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CRYSTAL LN
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1714
Mailing Address - Country:US
Mailing Address - Phone:518-785-4705
Mailing Address - Fax:
Practice Address - Street 1:6 CRYSTAL LN
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1714
Practice Address - Country:US
Practice Address - Phone:518-785-4705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-13
Last Update Date:2008-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007750-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics