Provider Demographics
NPI:1083816870
Name:BOUCHARD, LISA (LMT, LAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:LMT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-3102
Mailing Address - Country:US
Mailing Address - Phone:207-286-8416
Mailing Address - Fax:207-286-8440
Practice Address - Street 1:311 ALFRED ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-3127
Practice Address - Country:US
Practice Address - Phone:207-286-8416
Practice Address - Fax:207-286-8440
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC209171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME043580OtherANTHEM BCBS STAR #
ME043580OtherANTHEM BCBS STAR #