Provider Demographics
NPI:1174106884
Name:BOUCHARD, MATTHEW IAN (LICSW)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:IAN
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 LAKESIDE AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5911
Mailing Address - Country:US
Mailing Address - Phone:802-657-7090
Mailing Address - Fax:802-657-7078
Practice Address - Street 1:128 LAKESIDE AVE STE 260
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5911
Practice Address - Country:US
Practice Address - Phone:802-657-7087
Practice Address - Fax:802-657-7078
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01343971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical