Provider Demographics
NPI:1114505336
Name:BUTCHER, TRAVIS
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BUTCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 E UNION ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:PA
Mailing Address - Zip Code:17724-1208
Mailing Address - Country:US
Mailing Address - Phone:570-971-1434
Mailing Address - Fax:
Practice Address - Street 1:15900 US-6
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:PA
Practice Address - Zip Code:16947
Practice Address - Country:US
Practice Address - Phone:570-297-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE012704225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty