Provider Demographics
NPI:1043241722
Name:BUTLER, TRENT LYDELL (PT)
Entity Type:Individual
Prefix:MR
First Name:TRENT
Middle Name:LYDELL
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1883 HIGHWAY 43 S
Mailing Address - Street 2:SUITE C
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-8405
Mailing Address - Country:US
Mailing Address - Phone:601-859-2906
Mailing Address - Fax:601-859-0483
Practice Address - Street 1:1883 HIGHWAY 43 S
Practice Address - Street 2:SUITE C
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-8405
Practice Address - Country:US
Practice Address - Phone:601-859-2906
Practice Address - Fax:601-859-0483
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00147565OtherRRMEDICARE
MS512I650002OtherOLD MEDICARE PTAN
MS00126758Medicaid
MS302II655874OtherPROVIDER TRANSACTION ACCESS NUMBER
MSP00618853OtherUP MEDICARE RAILROAD
MS650000255Medicare ID - Type Unspecified
MS00126758Medicaid