Provider Demographics
NPI:1497791164
Name:BOUCHARD, RICHARD J JR (LCSW)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:BOUCHARD
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:BOUCHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 1933
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-1933
Mailing Address - Country:US
Mailing Address - Phone:207-650-6450
Mailing Address - Fax:
Practice Address - Street 1:605 US ROUTE 1 STE 20
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7675
Practice Address - Country:US
Practice Address - Phone:207-650-6450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC40091041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME264990099Medicaid
ME037017OtherANTHEM BC/BS PROVIDER NO.