Provider Demographics
NPI:1649925348
Name:BOUCHER, DIANA (LMSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:838 LAFAYETTE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-6863
Mailing Address - Country:US
Mailing Address - Phone:718-360-7449
Mailing Address - Fax:
Practice Address - Street 1:838 LAFAYETTE AVE APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-6863
Practice Address - Country:US
Practice Address - Phone:718-360-7449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089932101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)