Basic Information
| Provider Information | |||||||||
| NPI: | 1306596663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUCHARD | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 COLONY LN | ||||||||
| Address2: | |||||||||
| City: | HARTSELLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356405928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147069785 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1909 COMMERCE AVE | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350556151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567344688 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2022 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 330000014 | 05 | AL | MEDICAID |