Provider Demographics
NPI:1215144290
Name:BOISSELLE, PAULINE ANNE (OTR)
Entity type:Individual
Prefix:MS
First Name:PAULINE
Middle Name:ANNE
Last Name:BOISSELLE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1274
Mailing Address - Street 2:
Mailing Address - City:ST MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-1274
Mailing Address - Country:US
Mailing Address - Phone:928-871-2846
Mailing Address - Fax:
Practice Address - Street 1:ST. MICHAELS ASSOCIATION OF SPECIAL EDUCATION
Practice Address - Street 2:1 MILE N OF 264 MUSTANG ROAD
Practice Address - City:ST. MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511-0100
Practice Address - Country:US
Practice Address - Phone:928-871-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0049225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist