Provider Demographics
NPI:1437973161
Name:BOUTWELL, ROBYN LEANNNA
Entity type:Individual
Prefix:
First Name:ROBYN
Middle Name:LEANNNA
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2870 JOHNSON CORNER RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-5071
Mailing Address - Country:US
Mailing Address - Phone:912-237-6512
Mailing Address - Fax:
Practice Address - Street 1:2870 JOHNSON CORNER RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-5071
Practice Address - Country:US
Practice Address - Phone:912-237-6512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician