Basic Information
| Provider Information | |||||||||
| NPI: | 1932656154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUTIN | ||||||||
| FirstName: | MARLON | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3021 RUE PARC FONTAINE | ||||||||
| Address2: | APT 610 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701316949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043021323 | ||||||||
| FaxNumber: | 5043244573 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 COMMON ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701122401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043021323 | ||||||||
| FaxNumber: | 5043244573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2016 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LA | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.