Healthcare Provider Details

I. General information

NPI: 1285383679
Provider Name (Legal Business Name): KATELYN BOUTWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 PENDLETON DR
HEBRON CT
06248-1579
US

IV. Provider business mailing address

347 BOSTON HILL RD
ANDOVER CT
06232-1422
US

V. Phone/Fax

Practice location:
  • Phone: 860-228-9488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number002804
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: