Basic Information
| Provider Information | |||||||||
| NPI: | 1871501296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUTILIER | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757867200 | ||||||||
| FaxNumber: | 7753281718 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895022597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757867200 | ||||||||
| FaxNumber: | 7753281718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY0220 | NV | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.