Provider Demographics
NPI:1992904619
Name:BOUCHARD, ALLAN R (BS,PTA)
Entity type:Individual
Prefix:MR
First Name:ALLAN
Middle Name:R
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:BS,PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1236
Mailing Address - Country:US
Mailing Address - Phone:978-927-1090
Mailing Address - Fax:
Practice Address - Street 1:26 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1236
Practice Address - Country:US
Practice Address - Phone:978-927-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA118225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant