Provider Demographics
NPI:1538489968
Name:BOUCHER, CLYDE LOUIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:LOUIS
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 ROUTE 70 E STE V105
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-4101
Mailing Address - Country:US
Mailing Address - Phone:856-751-0505
Mailing Address - Fax:
Practice Address - Street 1:1930 ROUTE 70 E
Practice Address - Street 2:SUITE M 68
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2150
Practice Address - Country:US
Practice Address - Phone:856-751-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC01339000091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical