Basic Information
| Provider Information | |||||||||
| NPI: | 1437370327 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHARD BRAUN | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT, NCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 844 STATE RTE 22B | ||||||||
| Address2: | |||||||||
| City: | PERU | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185693440 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 NEW YORK RD | ||||||||
| Address2: | |||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129033981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185613803 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 05/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 011853-1 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 03427185 | 05 | NY | MEDICAID |