Provider Demographics
NPI:1992881908
Name:BOUTAH, RATHAPHONE LESLEY (LCSW)
Entity type:Individual
Prefix:
First Name:RATHAPHONE
Middle Name:LESLEY
Last Name:BOUTAH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 FENTON PKWY STE 107-9
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4746
Mailing Address - Country:US
Mailing Address - Phone:858-707-5205
Mailing Address - Fax:
Practice Address - Street 1:2307 FENTON PKWY STE 107-9
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4746
Practice Address - Country:US
Practice Address - Phone:858-707-5205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2023-10-10
Deactivation Date:2014-02-06
Deactivation Code:
Reactivation Date:2021-06-17
Provider Licenses
StateLicense IDTaxonomies
CA267741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical