Provider Demographics
NPI:1174814487
Name:BOUCHER, CARRIE ELAINE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:ELAINE
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HAYMAKER ST
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-3115
Mailing Address - Country:US
Mailing Address - Phone:540-449-4235
Mailing Address - Fax:
Practice Address - Street 1:210 PROFESSIONAL PARK DR SE STE 10
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6649
Practice Address - Country:US
Practice Address - Phone:540-605-8751
Practice Address - Fax:540-750-4062
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019006762225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist