Basic Information
| Provider Information | |||||||||
| NPI: | 1871078386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTHILETTE | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | DPT, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 981 HIGH HOUSE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275133510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 S STRATFORD RD STE 523 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367654703 | ||||||||
| FaxNumber: | 3367651396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2018 | ||||||||
| LastUpdateDate: | 04/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305212305 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P21138 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.