Provider Demographics
NPI:1316983562
Name:BOUTELLE, RONALD CHARLES (PHD, PSYD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:CHARLES
Last Name:BOUTELLE
Suffix:
Gender:M
Credentials:PHD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24677 SADDLE PEAK RD
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-3072
Mailing Address - Country:US
Mailing Address - Phone:310-317-6784
Mailing Address - Fax:310-317-6784
Practice Address - Street 1:12304 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2551
Practice Address - Country:US
Practice Address - Phone:310-317-6784
Practice Address - Fax:310-317-6784
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10792103TC0700X, 103TP0814X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis