Provider Demographics
NPI:1114500758
Name:BOUCHARD, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BOUCHARD
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 1:125 W 126TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4412
Mailing Address - Country:US
Mailing Address - Phone:774-365-9994
Mailing Address - Fax:
Practice Address - Street 1:16 CYPRESS AVE # STUDIO27
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-2340
Practice Address - Country:US
Practice Address - Phone:724-856-1542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist