Provider Demographics
NPI:1548511785
Name:BOUCHER, NICOLE (BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:301 EDGEWATER PL STE 100
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1281
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:72 JACQUES AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610
Practice Address - Country:US
Practice Address - Phone:508-421-4453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst