MEDICARE: TRICIA 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	1041C0700X	Clinical Social Worker	3376	CT

General Provider Information

NPI Number	:	1942757778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRICIA BOUCHARD

Provider Business Mailing Address
First Line	:	74 BUCKINGHAM STREET
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06702
Country	:	US
Telephone Number	:	203-819-9223
Fax Number	:

Provider Business Practice Location Address
First Line	:	74 BUCKINGHAM ST
Second Line	:
City	:	WATERBURY
State	:	CT
Zip	:	06710-1908
Country	:	US
Telephone Number	:	203-819-9223
Fax Number	:

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

Provider Enumeration Date	:	09/09/2016
Last Update Date	:	09/09/2016

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