Provider Demographics
NPI:1306243456
Name:BOUCHARD, MICHELLE RENAE (1-14-16524)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENAE
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:1-14-16524
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 HATFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-5389
Mailing Address - Country:US
Mailing Address - Phone:760-271-9998
Mailing Address - Fax:
Practice Address - Street 1:734 HATFIELD DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-5389
Practice Address - Country:US
Practice Address - Phone:760-271-9998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-16524103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst