Provider Demographics
NPI:1134592819
Name:BOUTON, DEMETRIA J (RSW)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:J
Last Name:BOUTON
Suffix:
Gender:F
Credentials:RSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 MADELINE LN
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-3995
Mailing Address - Country:US
Mailing Address - Phone:504-231-1094
Mailing Address - Fax:504-265-8340
Practice Address - Street 1:1049 MADELINE LN
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70460-3995
Practice Address - Country:US
Practice Address - Phone:504-231-1094
Practice Address - Fax:504-265-8340
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8509104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker