Provider Demographics
NPI:1568674810
Name:BOULANGER, SUSAN ALAINE (LMP, NCTMB, NCMMT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ALAINE
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:LMP, NCTMB, NCMMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7529 BEVERLY BLVD
Mailing Address - Street 2:BOX 2
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-6770
Mailing Address - Country:US
Mailing Address - Phone:425-308-6093
Mailing Address - Fax:425-322-3182
Practice Address - Street 1:7529 BEVERLY BLVD
Practice Address - Street 2:BOX 2
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-6770
Practice Address - Country:US
Practice Address - Phone:425-308-6093
Practice Address - Fax:425-322-3182
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA15833171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor