Provider Demographics
NPI:1285093666
Name:BOUCHER, MEGAN (PTA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BOUCHER
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 1:122 BOWDOIN ST APT 107
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-2709
Mailing Address - Country:US
Mailing Address - Phone:413-519-3494
Mailing Address - Fax:
Practice Address - Street 1:122 BOWDOIN ST APT 107
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-2709
Practice Address - Country:US
Practice Address - Phone:413-519-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant