Provider Demographics
NPI:1033785027
Name:BOUCHE, MATTHEW CHARLES (PT, CSCS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHARLES
Last Name:BOUCHE
Suffix:
Gender:M
Credentials:PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3519 SAWGRASS TRL E
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1367
Mailing Address - Country:US
Mailing Address - Phone:920-621-7074
Mailing Address - Fax:
Practice Address - Street 1:2155 FORD PARKWAY
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1862
Practice Address - Country:US
Practice Address - Phone:651-696-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118062251X0800X, 2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic