Provider Demographics
NPI:1487868642
Name:BOUCHARD, MICHELLE (DC , PC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:DC , PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 BROADWAY SUITE 1205
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:SUITE 1205
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010
Practice Address - Country:US
Practice Address - Phone:212-358-0820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008233-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor