Provider Demographics
NPI:1639335623
Name:BOUCHER, DEANA S (RD)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:S
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:DEANA
Other - Middle Name:S
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1625 STRAITS TPKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1836
Mailing Address - Country:US
Mailing Address - Phone:203-572-9512
Mailing Address - Fax:
Practice Address - Street 1:590 MIDDLEBURY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-2562
Practice Address - Country:US
Practice Address - Phone:203-758-1004
Practice Address - Fax:203-758-1551
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000847133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered