Provider Demographics
NPI:1104969849
Name:BOUTOT, EVELYN AMANDA (PHD)
Entity type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:AMANDA
Last Name:BOUTOT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BROWN ROCK TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-3306
Mailing Address - Country:US
Mailing Address - Phone:512-983-8388
Mailing Address - Fax:
Practice Address - Street 1:5900 BROWN ROCK TRL
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-3306
Practice Address - Country:US
Practice Address - Phone:512-983-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1041740103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral