Healthcare Provider Details

I. General information

NPI: 1851457030
Provider Name (Legal Business Name): HEATHER ANNE BOURDEAU O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 01/30/2024
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 HARTFORD AVE
WHITE RIVER JUNCTION VT
05001-8031
US

IV. Provider business mailing address

587 HARTFORD AVE
WHITE RIVER JUNCTION VT
05001-8031
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-4887
  • Fax:
Mailing address:
  • Phone: 802-295-4887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4373-TP
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number4373-TP
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number030.0133973
License Number StateVT
# 4
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4373-TP
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: