Provider Demographics
NPI:1982329793
Name:BOUCHER, MADELINE L (APSW)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:L
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:POLEWSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:NORTHWEST COUNSELING & GUIDANCE CLINIC
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:SIREN
Mailing Address - State:WI
Mailing Address - Zip Code:54872-0309
Mailing Address - Country:US
Mailing Address - Phone:715-349-7069
Mailing Address - Fax:888-625-8634
Practice Address - Street 1:1119 W KENNEDY AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136-2213
Practice Address - Country:US
Practice Address - Phone:920-364-9668
Practice Address - Fax:888-625-8634
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132671-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker