Provider Demographics
NPI:1639668049
Name:BOUCHER, ELIZABETH RODMAN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:RODMAN
Last Name:BOUCHER
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 1:54 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-4399
Mailing Address - Country:US
Mailing Address - Phone:508-484-5797
Mailing Address - Fax:
Practice Address - Street 1:54 FRONT ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-4399
Practice Address - Country:US
Practice Address - Phone:508-484-5797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MA1209591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical