Provider Demographics
NPI:1780740456
Name:BOUTIN, KEVIN (OT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CLARK AVE # A
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-2801
Mailing Address - Country:US
Mailing Address - Phone:662-840-0535
Mailing Address - Fax:662-842-7915
Practice Address - Street 1:90 CLARK AVE # A
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-2801
Practice Address - Country:US
Practice Address - Phone:662-840-0535
Practice Address - Fax:662-842-7915
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1239225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123797Medicaid