Provider Demographics
NPI:1013919992
Name:BOUCHARD, KRISTY SUE (DC)
Entity Type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:SUE
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KRISTY
Other - Middle Name:SUE
Other - Last Name:PLETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 4511
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099
Mailing Address - Country:US
Mailing Address - Phone:248-906-2225
Mailing Address - Fax:
Practice Address - Street 1:308 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1742
Practice Address - Country:US
Practice Address - Phone:248-906-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007569111N00000X
CO6385111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP06870001Medicare ID - Type Unspecified
MIU93506Medicare UPIN