MEDICARE: VALERIE A BOUCHARD PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071005117	IL

General Provider Information

NPI Number	:	1275653610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VALERIE A BOUCHARD PSYD

Provider Business Mailing Address
First Line	:	125 S WILKE RD
Second Line	:	SUITE 202
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1534
Country	:	US
Telephone Number	:	847-841-5110
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 S WILKE RD
Second Line	:	SUITE 202
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1534
Country	:	US
Telephone Number	:	847-841-5110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	07/08/2007

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