Provider Demographics
NPI:1225475254
Name:BOUTWELL, AUDREY (MT-BC)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 S RUSTIC LN
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-9355
Mailing Address - Country:US
Mailing Address - Phone:812-309-9795
Mailing Address - Fax:
Practice Address - Street 1:621 S CULLEN AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4137
Practice Address - Country:US
Practice Address - Phone:812-491-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10373225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist