Provider Demographics
NPI:1255852703
Name:BOUCHARD, WANDA BURLESON (MA, LPC, NCC)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:BURLESON
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2982 E HEARTLEAF LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5065
Mailing Address - Country:US
Mailing Address - Phone:208-949-6720
Mailing Address - Fax:
Practice Address - Street 1:2589 S FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2325
Practice Address - Country:US
Practice Address - Phone:208-991-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5859101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor