=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003282476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE MICHELLE BOUTIN LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2015
-----------------------------------------------------
Last Update Date | 08/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 W 34TH ST RM 1200 INTEGRITY SENIOR SERVICES
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-494-2858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9413 211TH ST
-----------------------------------------------------
City | QUEENS VILLAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11428-1526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-605-4869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 094955
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------