Provider Demographics
NPI:1821438011
Name:BOUCHOUCHA, GRACE CATHERINE (LCSWA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:CATHERINE
Last Name:BOUCHOUCHA
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16825 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8688
Mailing Address - Country:US
Mailing Address - Phone:704-305-7856
Mailing Address - Fax:
Practice Address - Street 1:16825 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8688
Practice Address - Country:US
Practice Address - Phone:704-305-7856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0080281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical