Provider Demographics
NPI:1104145945
Name:BOUCHARDTHOMPSON, JOY IRENE (LMT)
Entity type:Individual
Prefix:MS
First Name:JOY
Middle Name:IRENE
Last Name:BOUCHARDTHOMPSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N HAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-7316
Mailing Address - Country:US
Mailing Address - Phone:407-474-0360
Mailing Address - Fax:407-328-7557
Practice Address - Street 1:105 N HAMPTON CT
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-7316
Practice Address - Country:US
Practice Address - Phone:407-474-0360
Practice Address - Fax:407-328-7557
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA53616225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist