Provider Demographics
NPI:1275209868
Name:BOUTIN, BLISS WENKER (MA)
Entity type:Individual
Prefix:
First Name:BLISS
Middle Name:WENKER
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 FRIENDSHIP ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-3020
Mailing Address - Country:US
Mailing Address - Phone:916-799-5659
Mailing Address - Fax:
Practice Address - Street 1:272 NW MEDICAL LOOP STE E
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5545
Practice Address - Country:US
Practice Address - Phone:541-900-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC8389101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health