Provider Demographics
NPI:1326501859
Name:BOUTTE, MYESHA MARIE
Entity Type:Individual
Prefix:
First Name:MYESHA
Middle Name:MARIE
Last Name:BOUTTE
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 1:5680 CONCORD RD APT 10
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77708-5310
Mailing Address - Country:US
Mailing Address - Phone:409-550-4976
Mailing Address - Fax:
Practice Address - Street 1:5680 CONCORD RD APT 10
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77708-5310
Practice Address - Country:US
Practice Address - Phone:409-550-4976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care