Provider Demographics
NPI:1912549569
Name:BOUCHARD, MIKAYLAH M
Entity Type:Individual
Prefix:
First Name:MIKAYLAH
Middle Name:M
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 SE ORIENT DR APT 3129
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-5262
Mailing Address - Country:US
Mailing Address - Phone:971-409-1832
Mailing Address - Fax:
Practice Address - Street 1:8303 SW LOCUST ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8816
Practice Address - Country:US
Practice Address - Phone:503-645-3581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator