Provider Demographics
NPI:1013586411
Name:BUTLER, BETHANY A (LMBT 19019)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:A
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LMBT 19019
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 TAMMY CT
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6579
Mailing Address - Country:US
Mailing Address - Phone:704-620-4545
Mailing Address - Fax:
Practice Address - Street 1:5509 MONROE ROAD
Practice Address - Street 2:WILLIAMSBURG TWO SUITE 205
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212
Practice Address - Country:US
Practice Address - Phone:980-549-1478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty