Provider Demographics
NPI:1396478772
Name:BOUSHELL, KAITLIN (PT, DPT, CBIS)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:BOUSHELL
Suffix:
Gender:F
Credentials:PT, DPT, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5051 GREENSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4354
Mailing Address - Country:US
Mailing Address - Phone:410-601-1763
Mailing Address - Fax:
Practice Address - Street 1:5051 GREENSPRING AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-4354
Practice Address - Country:US
Practice Address - Phone:410-601-7360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist