Provider Demographics
NPI:1396807764
Name:BOUCHARD, ERIC S (PT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 ROOSEVELT TRL UNIT 2
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-4983
Mailing Address - Country:US
Mailing Address - Phone:207-661-2828
Mailing Address - Fax:
Practice Address - Street 1:584 ROOSEVELT TRL UNIT 2
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4983
Practice Address - Country:US
Practice Address - Phone:207-661-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM8722Medicare ID - Type Unspecified
ME267920099Medicaid
ME027690OtherANTHEM BCBS