Provider Demographics
NPI:1801958566
Name:BOUCHER, MARYANN (PSYD)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 PUMP RD # 1136
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1115
Mailing Address - Country:US
Mailing Address - Phone:804-455-8522
Mailing Address - Fax:
Practice Address - Street 1:3540 PUMP RD # 1136
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1115
Practice Address - Country:US
Practice Address - Phone:804-455-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004207103TC0700X
VA0810007450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical