Provider Demographics
NPI:1952698821
Name:BOUTELLE, MARILYN (OTA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:BOUTELLE
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 ELEANOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-2231
Mailing Address - Country:US
Mailing Address - Phone:651-343-3888
Mailing Address - Fax:
Practice Address - Street 1:1119 OWENS ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-4316
Practice Address - Country:US
Practice Address - Phone:651-343-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201686224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant