MEDICARE: DR. RONALD CHARLES BOUTELLE PHD, PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY10792	CA
2	103TP0814X	Psychoanalysis Psychologist	PSY10792	CA
3	103T00000X	Psychologist	PSY10792	CA

General Provider Information

NPI Number	:	1316983562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD CHARLES BOUTELLE PHD, PSYD

Provider Business Mailing Address
First Line	:	24677 SADDLE PEAK RD
Second Line	:
City	:	MALIBU
State	:	CA
Zip	:	90265-3072
Country	:	US
Telephone Number	:	310-317-6784
Fax Number	:	310-317-6784

Provider Business Practice Location Address
First Line	:	12304 SANTA MONICA BLVD
Second Line	:	SUITE 106
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2551
Country	:	US
Telephone Number	:	310-317-6784
Fax Number	:	310-317-6784

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	09/11/2025

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