Provider Demographics
NPI:1508359845
Name:BOUTOTE, ROBERT LOUIS (ATC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOUIS
Last Name:BOUTOTE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:401 W KENNEDY BLVD # I
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1450
Mailing Address - Country:US
Mailing Address - Phone:813-253-6264
Mailing Address - Fax:813-257-7746
Practice Address - Street 1:401 W KENNEDY BLVD # I
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-1450
Practice Address - Country:US
Practice Address - Phone:813-253-6264
Practice Address - Fax:813-257-7746
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL39572255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAL3957OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH
2000011101OtherBOARD OF CERTIFICATION
36422OtherNATIONAL ATHLETIC TRAINERS ASSOCIATION