Provider Demographics
NPI:1548762438
Name:BOUTSY, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BOUTSY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 DOWNEY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1208
Mailing Address - Country:US
Mailing Address - Phone:209-341-1824
Mailing Address - Fax:209-523-1296
Practice Address - Street 1:121 DOWNEY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1208
Practice Address - Country:US
Practice Address - Phone:209-341-1824
Practice Address - Fax:209-523-1296
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1626385106S00000X
390200000X
CA134386106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program