Healthcare Provider Details

I. General information

NPI: 1639429624
Provider Name (Legal Business Name): NINA E BOULARD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 UNION ST STE 9
BANGOR ME
04401-3050
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-4037
  • Fax: 207-973-5845
Mailing address:
  • Phone: 207-973-4037
  • Fax: 207-973-5845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPS1146
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: