Healthcare Provider Details

I. General information

NPI: 1801951124
Provider Name (Legal Business Name): DAVE ROCH BOUCHARD MSW, LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CHURCH ST
LACONIA NH
03246-3432
US

IV. Provider business mailing address

189 UPPER BAY RD
SANBORNTON NH
03269-2722
US

V. Phone/Fax

Practice location:
  • Phone: 603-524-1100
  • Fax:
Mailing address:
  • Phone: 603-524-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number575
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: