Provider Demographics
NPI:1376980227
Name:BOUTTE, WANDA RAMONA
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:RAMONA
Last Name:BOUTTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:RAMONA
Other - Last Name:BOUTTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:5241 MEDEA WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8727
Mailing Address - Country:US
Mailing Address - Phone:510-469-1136
Mailing Address - Fax:
Practice Address - Street 1:5241 MEDEA WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8727
Practice Address - Country:US
Practice Address - Phone:510-469-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-02
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293646222Q00000X
CA293311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA206171OtherNORIDIAN MEDICARE
CA1376980227OtherALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES