Basic Information
| Provider Information | |||||||||
| NPI: | 1649886870 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUTIETTE | ||||||||
| FirstName: | KATHRYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38809 S MARION DR | ||||||||
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| City: | RICHVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565769606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184572878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 311 JEFFERSON ST N | ||||||||
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| City: | WADENA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564821308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186317475 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2020 | ||||||||
| LastUpdateDate: | 09/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 106303 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.