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NPI Code Detail

MEDICARE: MS. DAIL MARIE BOUCHARD LADC-1, CADAC

MEDICARE: MS. DAIL MARIE BOUCHARD LADC-1, CADAC
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
1101YA0400XAddiction (Substance Use Disorder) Counselor477MA

General Provider Information

NPI Number : 1679880165
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. DAIL MARIE BOUCHARD LADC-1, CADAC
Provider Business Mailing Address
First Line : 111 EDGARTOWN VINEYARD HAVEN RD
Second Line :
City : VINEYARD HAVEN
State : MA
Zip : 02568-4036
Country : US
Telephone Number : 508-693-7900
Fax Number : 508-696-0401
Provider Business Practice Location Address
First Line : 111 EDGARTOWN VINEYARD HAVEN RD
Second Line :
City : VINEYARD HAVEN
State : MA
Zip : 02568-4036
Country : US
Telephone Number : 508-693-7900
Fax Number : 508-696-0401
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/07/2010
Last Update Date : 09/07/2010

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