Provider Demographics
NPI:1942412499
Name:BOUCHER, ERICK MATTHEW (ATC)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:MATTHEW
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 BENT OAK DR
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 E COOKE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3111
Practice Address - Country:US
Practice Address - Phone:614-268-8671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.0022092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer