Provider Demographics
NPI:1215612189
Name:BOUCHAREB, RENEE DEBORAH THERRIEN
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:DEBORAH THERRIEN
Last Name:BOUCHAREB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:DEBORAH
Other - Last Name:THERRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6776 LAKE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1192
Mailing Address - Country:US
Mailing Address - Phone:651-784-7007
Mailing Address - Fax:
Practice Address - Street 1:6776 LAKE DR STE 220
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1192
Practice Address - Country:US
Practice Address - Phone:651-784-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist