Provider Demographics
NPI:1053987958
Name:BOUTWELL, MADISON DIANE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:DIANE
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 1:6766 QUEENSLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3023
Mailing Address - Country:US
Mailing Address - Phone:763-645-9335
Mailing Address - Fax:
Practice Address - Street 1:8980 ZACHARY LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4018
Practice Address - Country:US
Practice Address - Phone:612-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician