Provider Demographics
NPI:1104573575
Name:BOUTWELL, MADISON (MSAT, ATC, LAT)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:BOUTWELL
Suffix:
Gender:F
Credentials:MSAT, ATC, LAT
Other - Prefix:MISS
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:BARBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:397 N 600 E
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:IN
Mailing Address - Zip Code:46365-9607
Mailing Address - Country:US
Mailing Address - Phone:219-851-6845
Mailing Address - Fax:
Practice Address - Street 1:397 N 600 E
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:IN
Practice Address - Zip Code:46365-9607
Practice Address - Country:US
Practice Address - Phone:219-851-6845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
IN36003731A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer