Provider Demographics
NPI:1336993948
Name:BOUCHARD, ALYSSA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 COLLEGE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-458-5670
Mailing Address - Fax:
Practice Address - Street 1:19 COLLEGE RD
Practice Address - Street 2:SUITE D
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-458-5670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
212426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist