=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841716511
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUNE ELLEN BOUCHER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2017
-----------------------------------------------------
Last Update Date | 02/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1287 E DRUCKER ST
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-4031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-571-1120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1553 N MILWAUKEE ST # 338
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-8471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-519-6971
-----------------------------------------------------
Fax | 208-963-3056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LCSW-35956
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------