Provider Demographics
NPI:1043730088
Name:BOUCHARD, GEORGIEANNA (LMT APP)
Entity Type:Individual
Prefix:
First Name:GEORGIEANNA
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:LMT APP
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 45
Mailing Address - Street 2:
Mailing Address - City:IPSWICH
Mailing Address - State:MA
Mailing Address - Zip Code:01938-0045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 MARKET ST
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-2262
Practice Address - Country:US
Practice Address - Phone:978-356-0282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14405225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty