Provider Demographics
NPI:1346461233
Name:BUTKIEWICZ, BRIAN L (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:BUTKIEWICZ
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 1:11651 WEST GRANGE AVE
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130
Mailing Address - Country:US
Mailing Address - Phone:414-529-2228
Mailing Address - Fax:
Practice Address - Street 1:6735 W BRADLEY RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-3325
Practice Address - Country:US
Practice Address - Phone:414-354-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI777-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant