Provider Demographics
NPI:1164998928
Name:BOUTWELL, LACY
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:BOUTWELL
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 1:107 GRAND VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2747
Mailing Address - Country:US
Mailing Address - Phone:678-910-3940
Mailing Address - Fax:404-464-0819
Practice Address - Street 1:524 S HOUSTON LAKE RD STE B300
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9042
Practice Address - Country:US
Practice Address - Phone:678-910-3940
Practice Address - Fax:404-464-0819
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008941235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist