Provider Demographics
NPI:1508243312
Name:BOUTIN, LAURA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096-7513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 MAURICE DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-3270
Practice Address - Country:US
Practice Address - Phone:207-725-7495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MESP-2414235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14130627OtherASHA