Provider Demographics
NPI:1124232152
Name:BUTTRESS, AMANDA JEANICE (PT)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:JEANICE
Last Name:BUTTRESS
Suffix:
Gender:F
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:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:OK
Mailing Address - Zip Code:74370-0201
Mailing Address - Country:US
Mailing Address - Phone:918-688-5182
Mailing Address - Fax:
Practice Address - Street 1:1505 E STEVE OWENS BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-7917
Practice Address - Country:US
Practice Address - Phone:918-542-4101
Practice Address - Fax:918-542-4410
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist