Provider Demographics
NPI:1255825139
Name:BUTKOVICH, MOCHA-MYSTIQUE (CMT, LMT, ROSSITER)
Entity Type:Individual
Prefix:
First Name:MOCHA-MYSTIQUE
Middle Name:
Last Name:BUTKOVICH
Suffix:
Gender:F
Credentials:CMT, LMT, ROSSITER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7606 UNIVERSITY AVE STE B-1
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-2155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7606 UNIVERSITY AVE STE B-1
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-2155
Practice Address - Country:US
Practice Address - Phone:720-217-7992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004490225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty