1093794372 NPI number — DR. WAYNE CHARLES BOUCHER PSY.D, ABPP

Table of content: DR. WAYNE CHARLES BOUCHER PSY.D, ABPP (NPI 1093794372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093794372 NPI number — DR. WAYNE CHARLES BOUCHER PSY.D, ABPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUCHER
Provider First Name:
WAYNE
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D, ABPP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093794372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 788250
Provider Second Line Business Mailing Address:
MAGTFTC MCAGCC
Provider Business Mailing Address City Name:
TWENTYNINE PALMS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92278-8250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-830-2935
Provider Business Mailing Address Fax Number:
760-830-2755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROBERT E BUSH NAVAL HOSPTIAL
Provider Second Line Business Practice Location Address:
MAGTFTC MCAGCC
Provider Business Practice Location Address City Name:
TWENTYNINE PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92278-8250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-830-2935
Provider Business Practice Location Address Fax Number:
760-830-2755
Provider Enumeration Date:
01/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1614 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)