Provider Demographics
NPI:1124343058
Name:BOUCHER, ROBERTA BETH (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:BETH
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11,000 COUNTY RD 255
Mailing Address - Street 2:
Mailing Address - City:WESTCLIFFE
Mailing Address - State:CO
Mailing Address - Zip Code:81252
Mailing Address - Country:US
Mailing Address - Phone:719-429-3656
Mailing Address - Fax:
Practice Address - Street 1:11000 COUNTY ROAD 255
Practice Address - Street 2:
Practice Address - City:WESTCLIFFE
Practice Address - State:CO
Practice Address - Zip Code:81252-9514
Practice Address - Country:US
Practice Address - Phone:719-597-5043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-04
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA100293Medicare PIN