Provider Demographics
NPI:1104299775
Name:BOUCHARD, ELAINE NAOMI (CMT)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:NAOMI
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9437 FORT WORTH WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-1013
Mailing Address - Country:US
Mailing Address - Phone:530-388-0615
Mailing Address - Fax:
Practice Address - Street 1:2414 21ST ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2410
Practice Address - Country:US
Practice Address - Phone:530-388-0615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36438225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist