Provider Demographics
NPI:1205507365
Name:BOUCHARD, TAMMY H (LPTA)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:H
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 BLACKSMITH ARCH
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-4506
Mailing Address - Country:US
Mailing Address - Phone:757-739-4697
Mailing Address - Fax:
Practice Address - Street 1:3540 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-3641
Practice Address - Country:US
Practice Address - Phone:757-230-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000583225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant