Provider Demographics
NPI:1851548713
Name:BUTLER, MICHELLE K (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-1906
Mailing Address - Country:US
Mailing Address - Phone:318-841-0696
Mailing Address - Fax:318-841-0776
Practice Address - Street 1:2950 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-1906
Practice Address - Country:US
Practice Address - Phone:318-841-0696
Practice Address - Fax:318-841-0776
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202845015Medicare PIN