Provider Demographics
NPI:1023857349
Name:BOUTAIN, MICHELLE (CHW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BOUTAIN
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 122ND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-9590
Mailing Address - Country:US
Mailing Address - Phone:269-686-4585
Mailing Address - Fax:
Practice Address - Street 1:3255 122ND AVE STE 200
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9590
Practice Address - Country:US
Practice Address - Phone:269-686-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI95396175172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker