Provider Demographics
NPI:1649777822
Name:BUTA-BLAIR, KIMBERLY (DPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BUTA-BLAIR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:BUTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:1720 ABBEY RD STE A
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6363
Practice Address - Country:US
Practice Address - Phone:517-333-6692
Practice Address - Fax:517-333-6705
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist