Provider Demographics
NPI:1720062813
Name:GRANT-BEUTTLER, MARYBETH (PT, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARYBETH
Middle Name:
Last Name:GRANT-BEUTTLER
Suffix:
Gender:F
Credentials:PT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SKYSAIL DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1437
Mailing Address - Country:US
Mailing Address - Phone:949-644-6460
Mailing Address - Fax:570-489-5563
Practice Address - Street 1:19 SKYSAIL DR
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1437
Practice Address - Country:US
Practice Address - Phone:949-644-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33373225100000X, 2251N0400X, 2251P0200X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA163623OtherMEDPLUS
PW3742484OtherAETNA HMO
PABE1698593OtherHIGHMARK
PA819328OtherFIRST PRIORITY/BC/BS
PA9384434OtherPHCS
PA7780635OtherAETNA PPO