Provider Demographics
NPI:1710291356
Name:BOUCHARD-HALL, KEVIN ROBERT (PHYSICAL THERAPY)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROBERT
Last Name:BOUCHARD-HALL
Suffix:
Gender:M
Credentials:PHYSICAL THERAPY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12932
Mailing Address - Country:US
Mailing Address - Phone:518-873-2408
Mailing Address - Fax:518-873-3205
Practice Address - Street 1:66 PARK STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932-0000
Practice Address - Country:US
Practice Address - Phone:518-873-2408
Practice Address - Fax:518-873-3205
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP75321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist