Provider Demographics
NPI:1629549209
Name:BOUTTE, LE TASHA CHANTEL (RBT)
Entity Type:Individual
Prefix:
First Name:LE TASHA
Middle Name:CHANTEL
Last Name:BOUTTE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 N LOOP 336 W APT 635
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3466
Mailing Address - Country:US
Mailing Address - Phone:832-547-6154
Mailing Address - Fax:
Practice Address - Street 1:3400 N LOOP 336 W APT 635
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3466
Practice Address - Country:US
Practice Address - Phone:832-547-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician