Provider Demographics
NPI:1447916333
Name:BOUTIN, CHASTIDY
Entity type:Individual
Prefix:MRS
First Name:CHASTIDY
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 GREEN CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2885
Mailing Address - Country:US
Mailing Address - Phone:229-244-9688
Mailing Address - Fax:
Practice Address - Street 1:1817 GREEN CIR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2885
Practice Address - Country:US
Practice Address - Phone:229-244-9688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
GACSW009362104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical