Provider Demographics
NPI:1093476582
Name:BOUCHER, BARBARA ANN
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:ANN
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 1:111 2ND AVE NE STE 304A
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3444
Mailing Address - Country:US
Mailing Address - Phone:201-258-9850
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE NE STE 304A
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3444
Practice Address - Country:US
Practice Address - Phone:201-258-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC060421001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty