Healthcare Provider Details

I. General information

NPI: 1992881908
Provider Name (Legal Business Name): RATHAPHONE LESLEY BOUTAH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date: 02/06/2014
Reactivation Date: 06/17/2021

III. Provider practice location address

2307 FENTON PKWY STE 107-9
SAN DIEGO CA
92108-4746
US

IV. Provider business mailing address

2307 FENTON PKWY STE 107-9
SAN DIEGO CA
92108-4746
US

V. Phone/Fax

Practice location:
  • Phone: 858-707-5205
  • Fax:
Mailing address:
  • Phone: 858-707-5205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number26774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: