Provider Demographics
NPI:1952026114
Name:BOUTIN, SAMANTHA (LLMSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:800-395-3223
Mailing Address - Fax:248-620-6405
Practice Address - Street 1:42669 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1653
Practice Address - Country:US
Practice Address - Phone:800-395-3223
Practice Address - Fax:248-620-6405
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511087371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical