Provider Demographics
NPI:1205819273
Name:BOUCHER, KELLY A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 DEWITT LOOP # R2.210
Mailing Address - Street 2:
Mailing Address - City:FORT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5285
Mailing Address - Country:US
Mailing Address - Phone:571-231-1356
Mailing Address - Fax:571-231-6626
Practice Address - Street 1:9501 FARRELL RD
Practice Address - Street 2:APHP 5TH FLOOR
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5901
Practice Address - Country:US
Practice Address - Phone:703-805-0948
Practice Address - Fax:703-805-9024
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040061821041C0700X
VA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical