Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
Y | 101YM0800X | Mental Health Counselor | ||
N | 101YS0200X | School Counselor |
NPI | 1053759944 |
---|---|
Provider Name | Tiffany Bouchard |
First Address | Monmouth, OR 97361-0421 |
Second Address | Dallas, OR 97338-1922 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2013 |
Last Update Date | 12/06/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
152660 | (05) | OR |