Basic Information
| Provider Information | |||||||||
| NPI: | 1225472806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHARD | ||||||||
| FirstName: | ALEXANDRIA | ||||||||
| MiddleName: | MADELINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOUCHARD | ||||||||
| OtherFirstName: | ALEXANDRIA | ||||||||
| OtherMiddleName: | MADELINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BA, MSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 WALL ST. | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036684111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9 BLODGET ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031043598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036684111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 174400000X | N | Other Service Providers | Specialist | 1041C0700X | 2289 | NH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.