Provider Demographics
NPI:1922138155
Name:BOUTROS, NICHOLAS D (MA, CCMHC, LMHC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:D
Last Name:BOUTROS
Suffix:
Gender:M
Credentials:MA, CCMHC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CRAFTS AVE STE 2R
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3806
Mailing Address - Country:US
Mailing Address - Phone:413-207-2573
Mailing Address - Fax:
Practice Address - Street 1:8 CRAFTS AVE STE 2R
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3806
Practice Address - Country:US
Practice Address - Phone:413-207-2573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000007601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health