Provider Demographics
NPI:1528418076
Name:MOUTON, KATHRYN (LCSW-BACS)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:MOUTON
Suffix:
Gender:F
Credentials:LCSW-BACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 ARDMORE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5417
Mailing Address - Country:US
Mailing Address - Phone:337-802-8871
Mailing Address - Fax:
Practice Address - Street 1:825 ARDMORE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5417
Practice Address - Country:US
Practice Address - Phone:337-802-8871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2916104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker