Provider Demographics
NPI:1528394608
Name:BUTLER, ANDREA JOY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:JOY
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10915 SE STARK ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216
Mailing Address - Country:US
Mailing Address - Phone:503-261-1120
Mailing Address - Fax:503-261-8936
Practice Address - Street 1:23479 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2962
Practice Address - Country:US
Practice Address - Phone:503-667-9300
Practice Address - Fax:503-667-4975
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12802225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR$$$$$$$$$OtherLICENSED MASSAGE THERAPIST