Provider Demographics
NPI:1316599277
Name:BOUTIN, CODYE ANNE
Entity Type:Individual
Prefix:
First Name:CODYE
Middle Name:ANNE
Last Name:BOUTIN
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 1:5117 W PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1318
Mailing Address - Country:US
Mailing Address - Phone:623-628-2776
Mailing Address - Fax:
Practice Address - Street 1:5117 W PERSHING AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1318
Practice Address - Country:US
Practice Address - Phone:623-628-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA119172355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant