Provider Demographics
NPI:1609062793
Name:BOUTILIER, MICHELE A (LHIS)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:A
Last Name:BOUTILIER
Suffix:
Gender:F
Credentials:LHIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 ACORN LANE
Mailing Address - Street 2:
Mailing Address - City:POINT HARBOR
Mailing Address - State:NC
Mailing Address - Zip Code:27964
Mailing Address - Country:US
Mailing Address - Phone:252-441-2595
Mailing Address - Fax:252-441-2595
Practice Address - Street 1:2400 N. CROATOAN HWY
Practice Address - Street 2:SUITE G
Practice Address - City:KILL DEVIL HILLS
Practice Address - State:NC
Practice Address - Zip Code:27948
Practice Address - Country:US
Practice Address - Phone:252-441-2595
Practice Address - Fax:252-441-2595
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1003OtherNC HEARING AID LICENSE BO