Provider Demographics
NPI:1629740113
Name:BOUCHER, ALISA (MS)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 DIXIE HWY STE 362
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2077
Mailing Address - Country:US
Mailing Address - Phone:248-468-6823
Mailing Address - Fax:
Practice Address - Street 1:4233 ISLAND PARK DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-1916
Practice Address - Country:US
Practice Address - Phone:248-468-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education