Provider Demographics
NPI:1710664016
Name:BUTKIEWICZ, COURTNEY MEGAN (DT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MEGAN
Last Name:BUTKIEWICZ
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2194 W STATE ROAD 48
Mailing Address - Street 2:
Mailing Address - City:SHELBURN
Mailing Address - State:IN
Mailing Address - Zip Code:47879-8320
Mailing Address - Country:US
Mailing Address - Phone:812-240-3285
Mailing Address - Fax:
Practice Address - Street 1:2194 W STATE ROAD 48
Practice Address - Street 2:
Practice Address - City:SHELBURN
Practice Address - State:IN
Practice Address - Zip Code:47879-8320
Practice Address - Country:US
Practice Address - Phone:812-240-3285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist