Provider Demographics
NPI:1124419734
Name:BOUCHARD, CHRISTOPHER (MED, LPC)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4013
Mailing Address - Country:US
Mailing Address - Phone:214-872-9209
Mailing Address - Fax:
Practice Address - Street 1:2435 E HEBRON PKWY
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4427
Practice Address - Country:US
Practice Address - Phone:214-872-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70543101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional