Provider Demographics
NPI:1174820518
Name:BOUCHARD, MATTHEW JOSEPH (DPT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04493-4455
Mailing Address - Country:US
Mailing Address - Phone:207-659-2258
Mailing Address - Fax:
Practice Address - Street 1:404 STATE ST
Practice Address - Street 2:SUITE #610
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6623
Practice Address - Country:US
Practice Address - Phone:207-947-8381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT3456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist