Provider Demographics
NPI:1376921338
Name:BOUTTE, LESLIE MOSES (LPC-S, RPT-S)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MOSES
Last Name:BOUTTE
Suffix:
Gender:F
Credentials:LPC-S, RPT-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 N BUCKNER BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-3438
Mailing Address - Country:US
Mailing Address - Phone:214-771-8852
Mailing Address - Fax:214-238-6489
Practice Address - Street 1:1151 N BUCKNER BLVD STE 107
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3438
Practice Address - Country:US
Practice Address - Phone:214-771-8852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70164101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX329211201Medicaid