Healthcare Provider Details

I. General information

NPI: 1679880165
Provider Name (Legal Business Name): DAIL MARIE BOUCHARD LADC-1, CADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EDGARTOWN VINEYARD HAVEN RD
VINEYARD HAVEN MA
02568-4036
US

IV. Provider business mailing address

111 EDGARTOWN VINEYARD HAVEN RD
VINEYARD HAVEN MA
02568-4036
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-7900
  • Fax: 508-696-0401
Mailing address:
  • Phone: 508-693-7900
  • Fax: 508-696-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number477
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: