MEDICARE: BONNINE B BOUCHARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist	212406	ME

General Provider Information

NPI Number	:	1235465881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNINE B BOUCHARD

Provider Business Mailing Address
First Line	:	PO BOX 221
Second Line	:
City	:	GREENVILLE
State	:	ME
Zip	:	04441-0221
Country	:	US
Telephone Number	:	207-695-4579
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 MOOSEHEAD LAKE RD
Second Line	:
City	:	GREENVILLE
State	:	ME
Zip	:	04441-0221
Country	:	US
Telephone Number	:	207-695-4579
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2009
Last Update Date	:	11/02/2009

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