Provider Demographics
NPI:1437107711
Name:BOUTELLE, BARBARA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:JEAN
Last Name:BOUTELLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3070 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2310
Mailing Address - Country:US
Mailing Address - Phone:760-591-7750
Mailing Address - Fax:760-294-9813
Practice Address - Street 1:3070 MADISON ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2310
Practice Address - Country:US
Practice Address - Phone:760-434-6100
Practice Address - Fax:760-434-4583
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist