=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619258993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE BOUCHER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2011
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 FOLKSTONE RD APT B
-----------------------------------------------------
City | BROAD BROOK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06016-9434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-530-0722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 FOLKSTONE RD APT B
-----------------------------------------------------
City | BROAD BROOK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06016-9434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-530-0722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 000964
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 002338
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------