Healthcare Provider Details

I. General information

NPI: 1164180550
Provider Name (Legal Business Name): MELANIE BOUCHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 TALCOTT RD STE 50
WILLISTON VT
05495-8122
US

IV. Provider business mailing address

75 TALCOTT RD STE 50 #4
WILLISTON VT
05495-8122
US

V. Phone/Fax

Practice location:
  • Phone: 802-382-7102
  • Fax:
Mailing address:
  • Phone: 802-382-7102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number047.0133692
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: