Provider Demographics
NPI:1346346772
Name:BOUCHARD, SUSANNE MARGARETE (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUSANNE
Middle Name:MARGARETE
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:SUSANNE
Other - Middle Name:MARGARETE
Other - Last Name:GERLACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:160 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-4162
Mailing Address - Country:US
Mailing Address - Phone:207-622-9467
Mailing Address - Fax:207-623-2874
Practice Address - Street 1:160 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-4162
Practice Address - Country:US
Practice Address - Phone:207-622-9467
Practice Address - Fax:207-623-2874
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEQX2491Medicare PIN
MEUX2348Medicare PIN