1427090521 NPI number — MRS. MARYELLEN WILLETTE BOUTIN PHYSICAL THERAPIST

Table of content: MRS. MARYELLEN WILLETTE BOUTIN PHYSICAL THERAPIST (NPI 1427090521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427090521 NPI number — MRS. MARYELLEN WILLETTE BOUTIN PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUTIN
Provider First Name:
MARYELLEN
Provider Middle Name:
WILLETTE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427090521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 693
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-878-6656
Provider Business Mailing Address Fax Number:
802-878-6099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BLANCHARD COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-229-6398
Provider Business Practice Location Address Fax Number:
802-229-5137
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  0400003183 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: OVN 2233 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com