MEDICARE: MELISSA 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	175T00000X	Peer Specialist		CA

General Provider Information

NPI Number	:	1083173629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA BOUCHARD

Provider Business Mailing Address
First Line	:	4104 DELTA ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113-4113
Country	:	US
Telephone Number	:	619-264-0141
Fax Number	:

Provider Business Practice Location Address
First Line	:	4104 DELTA ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92113-4113
Country	:	US
Telephone Number	:	619-264-0141
Fax Number	:

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

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	03/13/2019

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Directions to “ MELISSA BOUCHARD ” Practice Location

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