Provider Demographics
NPI:1871078386
Name:BOUTHILETTE, SEAN PATRICK (DPT, PT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:BOUTHILETTE
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:981 HIGH HOUSE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3510
Mailing Address - Country:US
Mailing Address - Phone:919-388-0111
Mailing Address - Fax:919-388-8668
Practice Address - Street 1:1100 S STRATFORD RD STE 523
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3217
Practice Address - Country:US
Practice Address - Phone:336-765-4703
Practice Address - Fax:336-765-1396
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212305225100000X
NCP21138225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist