Provider Demographics
NPI:1609560903
Name:BUTZBACH, MICHELE SUSAN (LMT)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:SUSAN
Last Name:BUTZBACH
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 1:36 SMITHTOWN POLK BLVD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3201
Mailing Address - Country:US
Mailing Address - Phone:631-487-5439
Mailing Address - Fax:
Practice Address - Street 1:2364 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3502
Practice Address - Country:US
Practice Address - Phone:631-487-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013790-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist