Provider Demographics
NPI:1710748488
Name:BOUSSON, MITCHELL ALLEN JR
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:ALLEN
Last Name:BOUSSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4723
Mailing Address - Country:US
Mailing Address - Phone:209-558-4598
Mailing Address - Fax:
Practice Address - Street 1:500 N 9TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5814
Practice Address - Country:US
Practice Address - Phone:209-558-4598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95273030163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health