Provider Demographics
NPI:1801951124
Name:BOUCHARD, DAVE ROCH (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:ROCH
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 UPPER BAY RD
Mailing Address - Street 2:
Mailing Address - City:SANBORNTON
Mailing Address - State:NH
Mailing Address - Zip Code:03269-2722
Mailing Address - Country:US
Mailing Address - Phone:603-524-1100
Mailing Address - Fax:
Practice Address - Street 1:111 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LACONIA
Practice Address - State:NH
Practice Address - Zip Code:03246-3432
Practice Address - Country:US
Practice Address - Phone:603-524-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH5751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH889985AOtherMVP HEALTHCARE
NHH002311OtherCHAMPUS
NH1405991Y0NH01OtherANTHEM
NHH002311OtherCHAMPUS