Provider Demographics
NPI:1821589920
Name:BOUCHER, MALLORY LEANNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LEANNE
Last Name:BOUCHER
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 1:2718 DEBORAH DR
Mailing Address - Street 2:
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-0800
Mailing Address - Country:US
Mailing Address - Phone:913-608-2962
Mailing Address - Fax:
Practice Address - Street 1:900 ELMHURST BLVD
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-7402
Practice Address - Country:US
Practice Address - Phone:785-825-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-03324225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist