Provider Demographics
NPI:1649886870
Name:BOUTIETTE, KATHRYN (MOTR/L)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:BOUTIETTE
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38809 S MARION DR
Mailing Address - Street 2:
Mailing Address - City:RICHVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56576-9606
Mailing Address - Country:US
Mailing Address - Phone:218-457-2878
Mailing Address - Fax:
Practice Address - Street 1:231 FOX ST
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2337
Practice Address - Country:US
Practice Address - Phone:218-346-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106303225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist