Provider Demographics
NPI:1104222785
Name:BOUTIN, ANSLEY WALKER (PT)
Entity type:Individual
Prefix:
First Name:ANSLEY
Middle Name:WALKER
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ANSLEY
Other - Middle Name:ELIZABETH
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5520
Mailing Address - Fax:704-316-1848
Practice Address - Street 1:10305 HAMPTONS PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7221
Practice Address - Country:US
Practice Address - Phone:704-384-5520
Practice Address - Fax:704-316-1848
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC76482251X0800X
NCP7648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic