Provider Demographics
NPI:1205182888
Name:BOUCHER, BRANDON ARTHUR (DPT)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:ARTHUR
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:WOODSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08098-0146
Mailing Address - Country:US
Mailing Address - Phone:856-769-4564
Mailing Address - Fax:856-769-4637
Practice Address - Street 1:84 E GRANT ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WOODSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08098-1400
Practice Address - Country:US
Practice Address - Phone:856-769-4564
Practice Address - Fax:856-769-4637
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01449200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ197961Medicare UPIN