Provider Demographics
NPI:1568844348
Name:BOUTAGY, MELISSA (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BOUTAGY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:LEMBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:47 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1926
Mailing Address - Country:US
Mailing Address - Phone:860-409-4595
Mailing Address - Fax:860-409-4860
Practice Address - Street 1:385 CHURCH ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-6003
Practice Address - Country:US
Practice Address - Phone:203-453-2844
Practice Address - Fax:203-453-8772
Is Sole Proprietor?:No
Enumeration Date:2015-06-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist