Provider Demographics
NPI:1093794372
Name:BOUCHER, WAYNE CHARLES (PSYD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:CHARLES
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:PSYD, ABPP
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Mailing Address - Street 1:PO BOX 788250
Mailing Address - Street 2:MAGTFTC MCAGCC
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92278-8250
Mailing Address - Country:US
Mailing Address - Phone:760-830-2935
Mailing Address - Fax:760-830-2755
Practice Address - Street 1:ROBERT E BUSH NAVAL HOSPTIAL
Practice Address - Street 2:MAGTFTC MCAGCC
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-8250
Practice Address - Country:US
Practice Address - Phone:760-830-2935
Practice Address - Fax:760-830-2755
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1614103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical