Provider Demographics
NPI:1578929824
Name:BOUTTE', MARQUITA LARAE (BA)
Entity Type:Individual
Prefix:
First Name:MARQUITA
Middle Name:LARAE
Last Name:BOUTTE'
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 KNIGHT ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2507
Mailing Address - Country:US
Mailing Address - Phone:318-227-8390
Mailing Address - Fax:
Practice Address - Street 1:3003 KNIGHT ST STE 115
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2561
Practice Address - Country:US
Practice Address - Phone:318-398-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-31
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator