Provider Demographics
NPI:1548305295
Name:BOUCHER, RENEE M (MED, ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:M
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MED, ATC, LAT
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 442
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:MA
Mailing Address - Zip Code:01005-0442
Mailing Address - Country:US
Mailing Address - Phone:401-440-6369
Mailing Address - Fax:
Practice Address - Street 1:800 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:MA
Practice Address - Zip Code:01005-8906
Practice Address - Country:US
Practice Address - Phone:978-355-5041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA017702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer