Provider Demographics
NPI:1801160577
Name:DUCHARME, MARY LOUISE (OTR)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:DUCHARME
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:REEVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:383 PALM AVE
Mailing Address - Street 2:APT #N
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1136
Mailing Address - Country:US
Mailing Address - Phone:517-230-4475
Mailing Address - Fax:619-934-1886
Practice Address - Street 1:5441 BABCOCK RD
Practice Address - Street 2:STE. 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3993
Practice Address - Country:US
Practice Address - Phone:210-615-1117
Practice Address - Fax:210-253-3830
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11244171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider