Provider Demographics
NPI:1821299595
Name:BOUTROS, AUDREY SHARON (LMP)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:SHARON
Last Name:BOUTROS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 S PARKWAY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604
Mailing Address - Country:US
Mailing Address - Phone:360-666-1300
Mailing Address - Fax:360-666-5001
Practice Address - Street 1:119 S PARKWAY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604
Practice Address - Country:US
Practice Address - Phone:360-666-1300
Practice Address - Fax:360-666-5001
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA11768225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist