Healthcare Provider Details

I. General information

NPI: 1548305295
Provider Name (Legal Business Name): RENEE M BOUCHER M.ED, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SOUTH ST
BARRE MA
01005-8906
US

IV. Provider business mailing address

PO BOX 442
BARRE MA
01005-0442
US

V. Phone/Fax

Practice location:
  • Phone: 978-355-5041
  • Fax:
Mailing address:
  • Phone: 401-440-6369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number01770
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: