Provider Demographics
NPI:1376372383
Name:BOUCHER, ALEXANDRA GRACE
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:GRACE
Last Name:BOUCHER
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 1:161 BUTCHER RD STE B
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5685
Mailing Address - Country:US
Mailing Address - Phone:073-050-4407
Mailing Address - Fax:
Practice Address - Street 1:161 BUTCHER RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-5685
Practice Address - Country:US
Practice Address - Phone:707-302-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician