Provider Demographics
NPI:1740347822
Name:BOUCHER, MATTHEW (LICSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 ASHTON PKWY STE 204
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:RI
Mailing Address - Zip Code:02864-4827
Mailing Address - Country:US
Mailing Address - Phone:401-354-9708
Mailing Address - Fax:
Practice Address - Street 1:17 ASHTON PKWY STE 204
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:RI
Practice Address - Zip Code:02864-4827
Practice Address - Country:US
Practice Address - Phone:014-354-9708
Practice Address - Fax:401-333-4692
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW019671041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007059165Medicare PIN