Provider Demographics
NPI:1932979309
Name:BOUCHARD, SUSAN LEIGH (PTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEIGH
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830-4034
Mailing Address - Country:US
Mailing Address - Phone:978-697-4796
Mailing Address - Fax:
Practice Address - Street 1:60 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-4034
Practice Address - Country:US
Practice Address - Phone:978-697-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2769225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant