Provider Demographics
NPI:1760754972
Name:BOUTIN, SUSAN DENISE
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DENISE
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 1:140 LEPES RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-2631
Mailing Address - Country:US
Mailing Address - Phone:508-567-0675
Mailing Address - Fax:
Practice Address - Street 1:94 OBERY ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2130
Practice Address - Country:US
Practice Address - Phone:508-747-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3236224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant