Provider Demographics
NPI:1609184910
Name:MUTH, PAULETTE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:MARIE
Last Name:MUTH
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 1:12 CENTER ST
Mailing Address - Street 2:SUITE 4 - PHYSICAL THERAPY
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1769
Mailing Address - Country:US
Mailing Address - Phone:716-672-8790
Mailing Address - Fax:716-672-8794
Practice Address - Street 1:12 CENTER ST
Practice Address - Street 2:SUITE 4 - PHYSICAL THERAPY
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1769
Practice Address - Country:US
Practice Address - Phone:716-672-8790
Practice Address - Fax:716-672-8794
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033141-1225100000X
NYP77786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03289076Medicaid
NY03289076Medicaid