Provider Demographics
NPI:1073005765
Name:BOUCHER, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
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 1:62 WINGATE ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-5566
Mailing Address - Country:US
Mailing Address - Phone:207-877-4616
Mailing Address - Fax:
Practice Address - Street 1:62 WINGATE ST APT 3B
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01832
Practice Address - Country:US
Practice Address - Phone:207-877-4616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst