Provider Demographics
NPI:1437213469
Name:BOUTACOFF, LANA I (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:LANA
Middle Name:I
Last Name:BOUTACOFF
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 ASBURY ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1849
Mailing Address - Country:US
Mailing Address - Phone:651-645-7318
Mailing Address - Fax:651-645-0974
Practice Address - Street 1:570 ASBURY ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1849
Practice Address - Country:US
Practice Address - Phone:651-645-7318
Practice Address - Fax:651-645-0974
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2623103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist