Provider Demographics
NPI:1023201761
Name:BUTLER, BRANDON JACOB (LPTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JACOB
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 ROUND TOP HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39653-8140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 ROUND TOP HILL RD SE
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:MS
Practice Address - Zip Code:39653-8140
Practice Address - Country:US
Practice Address - Phone:601-384-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSLPTA4277225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant