Provider Demographics
NPI:1003429150
Name:BUTLER, MACKENNA (PTA)
Entity Type:Individual
Prefix:
First Name:MACKENNA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 HERD LAW RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-9239
Mailing Address - Country:US
Mailing Address - Phone:731-618-2114
Mailing Address - Fax:
Practice Address - Street 1:2036 US HIGHWAY 45 BYP S
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-2941
Practice Address - Country:US
Practice Address - Phone:731-855-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7475225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant