Provider Demographics
NPI:1790520195
Name:BOUTSIKOUDIS, REBECCA PRICE (LCSW)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:PRICE
Last Name:BOUTSIKOUDIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-2105
Mailing Address - Country:US
Mailing Address - Phone:203-249-2683
Mailing Address - Fax:
Practice Address - Street 1:1351 WASHINGTON BLVD FL 5
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2419
Practice Address - Country:US
Practice Address - Phone:203-388-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT78251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical