Provider Demographics
NPI:1619258993
Name:BOUCHER, CHRISTINE
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 FOLKSTONE RD APT B
Mailing Address - Street 2:
Mailing Address - City:BROAD BROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06016-9434
Mailing Address - Country:US
Mailing Address - Phone:860-530-0722
Mailing Address - Fax:
Practice Address - Street 1:25 FOLKSTONE RD APT B
Practice Address - Street 2:
Practice Address - City:BROAD BROOK
Practice Address - State:CT
Practice Address - Zip Code:06016-9434
Practice Address - Country:US
Practice Address - Phone:860-530-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000964101YA0400X
CT002338101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)