Provider Demographics
NPI:1396308409
Name:BOUTCHER, EMMADORA
Entity type:Individual
Prefix:
First Name:EMMADORA
Middle Name:
Last Name:BOUTCHER
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 1:300 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3658
Mailing Address - Country:US
Mailing Address - Phone:617-676-3652
Mailing Address - Fax:617-676-3463
Practice Address - Street 1:300 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-3658
Practice Address - Country:US
Practice Address - Phone:617-676-3652
Practice Address - Fax:617-676-3463
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2226711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical