Provider Demographics
NPI:1609227362
Name:BERRIAN, GILLIAN BUTSCH (PT)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:BUTSCH
Last Name:BERRIAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GILLIAN
Other - Middle Name:C
Other - Last Name:BUTSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 14161
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-4161
Mailing Address - Country:US
Mailing Address - Phone:307-734-1429
Mailing Address - Fax:307-734-1427
Practice Address - Street 1:4075 JARVIS LANE
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014
Practice Address - Country:US
Practice Address - Phone:802-272-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist