Provider Demographics
NPI:1235187550
Name:BARBARA JEAN BOUTELLE/CARLSBAD PHYSICAL THERAPY
Entity type:Organization
Organization Name:BARBARA JEAN BOUTELLE/CARLSBAD PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BOUTELLE
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:760-591-7750
Mailing Address - Street 1:600 S ANDREASEN DR
Mailing Address - Street 2:STE C
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-1917
Mailing Address - Country:US
Mailing Address - Phone:760-591-7750
Mailing Address - Fax:760-294-9813
Practice Address - Street 1:6195 CORNERSTONE CT
Practice Address - Street 2:STE. 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4728
Practice Address - Country:US
Practice Address - Phone:858-452-4324
Practice Address - Fax:858-452-3102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14620HMedicare PIN