Provider Demographics
NPI:1184430639
Name:BOUCHARD, GIANNA M (OTD)
Entity type:Individual
Prefix:
First Name:GIANNA
Middle Name:M
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 WALT WHITMAN RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4119
Mailing Address - Country:US
Mailing Address - Phone:631-683-5455
Mailing Address - Fax:
Practice Address - Street 1:259 WALT WHITMAN RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4119
Practice Address - Country:US
Practice Address - Phone:631-683-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029395225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist