Provider Demographics
NPI:1477803708
Name:BOUCHARD, CAROL J (LCPC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:J
Other - Last Name:MCBREAIRTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1975
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-1975
Mailing Address - Country:US
Mailing Address - Phone:207-206-9922
Mailing Address - Fax:
Practice Address - Street 1:5 COMMODORE DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-5957
Practice Address - Country:US
Practice Address - Phone:207-206-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4339101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional