Provider Demographics
NPI:1235972126
Name:BOUCHER, PAIGE
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N PATRIOT DR
Mailing Address - Street 2:
Mailing Address - City:HAINESVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1021
Mailing Address - Country:US
Mailing Address - Phone:224-247-8958
Mailing Address - Fax:
Practice Address - Street 1:633 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-4981
Practice Address - Country:US
Practice Address - Phone:312-248-9865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242007697235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist