Provider Demographics
NPI:1538283569
Name:BOUCHER, MARK LYNN (LMFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LYNN
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0713
Mailing Address - Country:US
Mailing Address - Phone:209-558-4464
Mailing Address - Fax:209-558-4450
Practice Address - Street 1:1208 9TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-0713
Practice Address - Country:US
Practice Address - Phone:209-558-4464
Practice Address - Fax:209-558-4450
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC20703106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherLMFT