Provider Demographics
NPI:1922259688
Name:BOUTRY, STEPHANIE ANN (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:BOUTRY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:CEARNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:5704 E LAKE SAMMAMISH PKWY SE
Mailing Address - Street 2:STE. #101
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029
Mailing Address - Country:US
Mailing Address - Phone:425-270-3323
Mailing Address - Fax:425-270-3326
Practice Address - Street 1:5704 E LAKE SAMMAMISH PKWY SE
Practice Address - Street 2:STE. #101
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029
Practice Address - Country:US
Practice Address - Phone:425-270-3323
Practice Address - Fax:425-270-3326
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60045917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8906642Medicare UPIN