Provider Demographics
NPI:1477694719
Name:BOUCHER-POTTER, LAURA ANNE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANNE
Last Name:BOUCHER-POTTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910
Mailing Address - Country:US
Mailing Address - Phone:401-270-2606
Mailing Address - Fax:
Practice Address - Street 1:420 FRUIT HILL AVE
Practice Address - Street 2:
Practice Address - City:N PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02911-2626
Practice Address - Country:US
Practice Address - Phone:401-353-3900
Practice Address - Fax:401-784-3549
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW017161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical