Provider Demographics
NPI:1154653038
Name:BOUTAN, MADELEINE (LMP)
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:BOUTAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 NE 55TH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5546
Mailing Address - Country:US
Mailing Address - Phone:843-259-8952
Mailing Address - Fax:
Practice Address - Street 1:2817 NE 55TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5529
Practice Address - Country:US
Practice Address - Phone:206-524-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60059470225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist