Basic Information
| Provider Information | |||||||||
| NPI: | 1477991008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHER | ||||||||
| FirstName: | CLAUDINE | ||||||||
| MiddleName: | MECHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CDAC INTERN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KAISI | ||||||||
| OtherFirstName: | CLAUDINE | ||||||||
| OtherMiddleName: | MECHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 205 S PRATT AVE | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897014730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758823945 | ||||||||
| FaxNumber: | 7758826126 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 E LONG ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897063129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758823945 | ||||||||
| FaxNumber: | 7758826126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.