Provider Demographics
NPI:1770653297
Name:BUTLER, BETHANY NUGENT
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:NUGENT
Last Name:BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:LYNNE
Other - Last Name:NUGENT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSPT
Mailing Address - Street 1:1704 WINSTON CT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-3573
Mailing Address - Country:US
Mailing Address - Phone:404-644-3917
Mailing Address - Fax:
Practice Address - Street 1:1 MCGARITY RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115
Practice Address - Country:US
Practice Address - Phone:770-360-9183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006906225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist