Provider Demographics
NPI:1255332938
Name:BUTLER, BONNIE ROSS (PT,OCS,CSCS)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ROSS
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PT,OCS,CSCS
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:ROSS
Other - Last Name:HENSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, OCS,CSCS
Mailing Address - Street 1:5151 S 900 E
Mailing Address - Street 2:#100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6657
Mailing Address - Country:US
Mailing Address - Phone:801-261-3321
Mailing Address - Fax:801-261-5942
Practice Address - Street 1:5151 S 900 E
Practice Address - Street 2:#100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-6601
Practice Address - Country:US
Practice Address - Phone:801-261-3321
Practice Address - Fax:801-261-5942
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT377196-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52947112802001OtherBLUE CROSS BLUE SHIELD
UT6400593OtherUNITED HEALTHCARE
UT5417OtherDMBA
UTCJ9402OtherRAILROAD MEDICARE
UTQM0000061055OtherALTIUS
UT69157OtherPEHP
UTQM0000061055OtherALTIUS
UT005580801Medicare ID - Type Unspecified