Provider Demographics
NPI:1851493282
Name:BOUTAULT, SUSAN J (HIS)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:J
Last Name:BOUTAULT
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 W BADILLO
Mailing Address - Street 2:#3 ACCURATE HEARING SYSTEMS
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723
Mailing Address - Country:US
Mailing Address - Phone:626-732-3510
Mailing Address - Fax:626-732-3520
Practice Address - Street 1:227 W BADILLO
Practice Address - Street 2:#3 ACCURATE HEARING SYSTEMS
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723
Practice Address - Country:US
Practice Address - Phone:626-732-3510
Practice Address - Fax:626-732-3520
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA1314237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA00013140Medicaid