=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255780219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN BOUTINEN PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2016
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2802 FLINTROCK TRCE STE 203
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-559-3877
-----------------------------------------------------
Fax | 425-249-3543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2802 FLINTROCK TRCE STE 203
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-1744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-559-3877
-----------------------------------------------------
Fax | 425-249-3543
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH60576837
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY60708359
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 40535
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------