Provider Demographics
NPI:1275209868
Name:BOUTIN, BLISS WENKER (MA)
Entity Type:Individual
Prefix:
First Name:BLISS
Middle Name:WENKER
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 SE TENINO ST APT 309
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6790
Mailing Address - Country:US
Mailing Address - Phone:916-799-5659
Mailing Address - Fax:
Practice Address - Street 1:6647 SE MILWAUKIE AVE STE B210
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5661
Practice Address - Country:US
Practice Address - Phone:971-258-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health