Provider Demographics
NPI:1194082198
Name:BOUCHER, DESIREE M
Entity type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:M
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 STORM DR
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-1912
Mailing Address - Country:US
Mailing Address - Phone:631-831-6040
Mailing Address - Fax:
Practice Address - Street 1:105 STORM DR
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-1912
Practice Address - Country:US
Practice Address - Phone:631-831-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist