Provider Demographics
NPI:1073374054
Name:BOUTWELL, LISA (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 MORRILL ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04967-4708
Mailing Address - Country:US
Mailing Address - Phone:207-487-1114
Mailing Address - Fax:
Practice Address - Street 1:167 SEBASTICOOK ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:ME
Practice Address - Zip Code:04967-4107
Practice Address - Country:US
Practice Address - Phone:207-416-5236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1570225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant