Provider Demographics
NPI:1811955115
Name:BOUTAUGH, THOMAS JOSEPH (MSPT)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:BOUTAUGH
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 NORWAY DR
Mailing Address - Street 2:
Mailing Address - City:MOHNTON
Mailing Address - State:PA
Mailing Address - Zip Code:19540-8743
Mailing Address - Country:US
Mailing Address - Phone:207-659-0857
Mailing Address - Fax:
Practice Address - Street 1:63-65 W CHURCH ST.
Practice Address - Street 2:SUITE 71
Practice Address - City:STEVENS
Practice Address - State:PA
Practice Address - Zip Code:17578
Practice Address - Country:US
Practice Address - Phone:717-335-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2423225100000X
PAPT022319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME248160000Medicaid
ME100546OtherANTHEM
ME7538245OtherAETNA
ME100546OtherANTHEM