Provider Demographics
NPI:1265067946
Name:BOUCHARD, CELESTE
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01850-2032
Mailing Address - Country:US
Mailing Address - Phone:978-821-7596
Mailing Address - Fax:
Practice Address - Street 1:1666 MASSACHUSETTS AVE
Practice Address - Street 2:SUITE 10, SECOND FLOOR
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420
Practice Address - Country:US
Practice Address - Phone:855-641-1379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MA2290191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician