Provider Demographics
NPI:1457901589
Name:BOUCHARD, DANIEL JOHN (RADT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 OCEAN FRONT WALK
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2403
Mailing Address - Country:US
Mailing Address - Phone:310-392-4925
Mailing Address - Fax:424-372-2990
Practice Address - Street 1:503 OCEAN FRONT WALK
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2403
Practice Address - Country:US
Practice Address - Phone:310-392-4925
Practice Address - Fax:424-372-2990
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)