Provider Demographics
NPI:1508990086
Name:BOUTILLETTE, ISABELLA CHAYNE (LPC MA)
Entity Type:Individual
Prefix:
First Name:ISABELLA CHAYNE
Middle Name:
Last Name:BOUTILLETTE
Suffix:
Gender:F
Credentials:LPC MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2451
Mailing Address - Country:US
Mailing Address - Phone:719-589-2786
Mailing Address - Fax:
Practice Address - Street 1:200 ROSS AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2451
Practice Address - Country:US
Practice Address - Phone:719-589-2786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1725101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health