Provider Demographics
NPI:1629129234
Name:BOUTILLETTE, CHARLOTTE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:BOUTILLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 LYMAN ST
Mailing Address - Street 2:
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-2633
Mailing Address - Country:US
Mailing Address - Phone:508-616-2249
Mailing Address - Fax:
Practice Address - Street 1:288 LYMAN ST
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-2633
Practice Address - Country:US
Practice Address - Phone:508-616-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5213224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant