Provider Demographics
NPI:1346783560
Name:BOUCHER, CHARLEEN (DPT)
Entity type:Individual
Prefix:
First Name:CHARLEEN
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 LOMA VISTA RD
Mailing Address - Street 2:STE A
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3015
Mailing Address - Country:US
Mailing Address - Phone:805-765-4773
Mailing Address - Fax:805-258-7039
Practice Address - Street 1:2149 ROCKLYN ST
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-3332
Practice Address - Country:US
Practice Address - Phone:760-331-8526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-19
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist