Provider Demographics
NPI:1760020200
Name:BOUCHER, MARY J (ND)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 NW CIRCLE BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1483
Mailing Address - Country:US
Mailing Address - Phone:541-224-6738
Mailing Address - Fax:541-224-8508
Practice Address - Street 1:922 NW CIRCLE BLVD STE 180
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1483
Practice Address - Country:US
Practice Address - Phone:541-224-6738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR951175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath