Provider Demographics
NPI:1215643762
Name:BOUCHER, ALICE (PT, DPT)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 SHAW MANSION RD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05677-8256
Mailing Address - Country:US
Mailing Address - Phone:860-921-8394
Mailing Address - Fax:
Practice Address - Street 1:1945 SHAW MANSION RD
Practice Address - Street 2:
Practice Address - City:WATERBURY CENTER
Practice Address - State:VT
Practice Address - Zip Code:05677-8256
Practice Address - Country:US
Practice Address - Phone:860-921-8394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0102990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist