Provider Demographics
NPI:1619923232
Name:BUTCHER, KANDICE (PT)
Entity Type:Individual
Prefix:
First Name:KANDICE
Middle Name:
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S MAIN ST
Mailing Address - Street 2:STE 220
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6626
Mailing Address - Country:US
Mailing Address - Phone:716-488-2322
Mailing Address - Fax:716-488-2574
Practice Address - Street 1:104 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOWANDA
Practice Address - State:NY
Practice Address - Zip Code:14070-1111
Practice Address - Country:US
Practice Address - Phone:716-532-2258
Practice Address - Fax:716-532-2321
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008228225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ2101396318Medicaid
NYJ2101396318Medicaid