Provider Demographics
NPI:1487682548
Name:BOUCHARD, TERESA ANN (DC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ANN
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 NASSAU BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5254
Mailing Address - Country:US
Mailing Address - Phone:516-248-3647
Mailing Address - Fax:516-414-8519
Practice Address - Street 1:371 NASSAU BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-5254
Practice Address - Country:US
Practice Address - Phone:516-248-3647
Practice Address - Fax:516-414-8519
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002932-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6687175OtherCIGNA
NY0878669OtherAETNA
NY0079064OtherGHI
NYX4495OtherBLUECROSS/BLUESHIELD
NY0878669OtherAETNA
NY6687175OtherCIGNA