Provider Demographics
NPI:1174867444
Name:BUTLER, ROBERTA LEE (PT)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:LEE
Last Name:BUTLER
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 1:1619 BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-6405
Mailing Address - Country:US
Mailing Address - Phone:360-379-4260
Mailing Address - Fax:360-379-4548
Practice Address - Street 1:1637 GRANT ST
Practice Address - Street 2:GRANT ST. ELEMENTARY SCHOOL
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-7622
Practice Address - Country:US
Practice Address - Phone:360-379-4260
Practice Address - Fax:360-379-4548
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist