MEDICARE: GRACE ETREL BOUTIN

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1528998226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE ETREL BOUTIN

Provider Business Mailing Address
First Line	:	455 FOX TRL
Second Line	:
City	:	OMRO
State	:	WI
Zip	:	54963-1198
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 FOX TRL
Second Line	:
City	:	OMRO
State	:	WI
Zip	:	54963-1198
Country	:	US
Telephone Number	:	920-303-2334
Fax Number	:

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

Provider Enumeration Date	:	05/22/2026
Last Update Date	:	05/22/2026

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Directions to “ GRACE ETREL BOUTIN ” Practice Location

Language	Start Address	Practice Location

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