Provider Demographics
NPI:1255320230
Name:BOUTILIER, BRIAN ERIC
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:ERIC
Last Name:BOUTILIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HODSKIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1175
Mailing Address - Country:US
Mailing Address - Phone:315-379-0992
Mailing Address - Fax:315-370-0993
Practice Address - Street 1:19 HODSKIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1175
Practice Address - Country:US
Practice Address - Phone:315-379-0992
Practice Address - Fax:315-370-0993
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018314-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist