Provider Demographics
NPI:1922057488
Name:BOUCHER, COLLEEN (MSPT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 BRIDLEPATH LANE
Mailing Address - Street 2:
Mailing Address - City:WIILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094
Mailing Address - Country:US
Mailing Address - Phone:856-562-0862
Mailing Address - Fax:
Practice Address - Street 1:603 N BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1619
Practice Address - Country:US
Practice Address - Phone:856-845-4488
Practice Address - Fax:856-853-5256
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA01064800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist