Provider Demographics
NPI:1326594243
Name:BUTKOVICH, THOMAS JACOB (PTA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JACOB
Last Name:BUTKOVICH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 MEDICAL DRIVE
Mailing Address - Street 2:LIFESPAN THERAPY
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032
Mailing Address - Country:US
Mailing Address - Phone:812-988-6666
Mailing Address - Fax:
Practice Address - Street 1:7120 CORBIN AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3618
Practice Address - Country:US
Practice Address - Phone:818-881-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005233A225200000X
CA48919225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant