Healthcare Provider Details

I. General information

NPI: 1164092961
Provider Name (Legal Business Name): BRIDGETTE BOUCHER LCSW, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/25/2021
Certification Date: 06/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 1ST AVE APT 4F
NEW YORK NY
10029-5091
US

IV. Provider business mailing address

2021 1ST AVE APT 4F
NEW YORK NY
10029-5091
US

V. Phone/Fax

Practice location:
  • Phone: 212-729-4549
  • Fax:
Mailing address:
  • Phone: 212-729-4549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number082710-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: