Provider Demographics
NPI:1962297135
Name:BOUCHER, SAMANTHA LYNN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:BOUCHER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SABLE CHASE
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-2126
Mailing Address - Country:US
Mailing Address - Phone:317-200-6667
Mailing Address - Fax:
Practice Address - Street 1:475 SABLE CHASE
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-2126
Practice Address - Country:US
Practice Address - Phone:317-200-6667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21405261225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist