Provider Demographics
NPI:1568007367
Name:BOUTIN, SAMANTHA ANNE
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:ANNE
Last Name:BOUTIN
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 1:10 N MAIN ST STE 305
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1901
Mailing Address - Country:US
Mailing Address - Phone:203-240-7075
Mailing Address - Fax:
Practice Address - Street 1:10 N MAIN ST STE 305
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1901
Practice Address - Country:US
Practice Address - Phone:203-240-7075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT46.003996101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional