Healthcare Provider Details

I. General information

NPI: 1619783784
Provider Name (Legal Business Name): KATELYN BOUSQUET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 HALE ST
BEVERLY MA
01915-2096
US

IV. Provider business mailing address

152 UPPER NEW HAMPTON RD
MEREDITH NH
03253-4219
US

V. Phone/Fax

Practice location:
  • Phone: 978-297-0585
  • Fax:
Mailing address:
  • Phone: 603-481-2812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: