Provider Demographics
NPI:1255847075
Name:BUTTKE, KAYLA ELIZABETH (COTA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:ELIZABETH
Last Name:BUTTKE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 1/2 W 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520-2041
Mailing Address - Country:US
Mailing Address - Phone:608-588-9168
Mailing Address - Fax:
Practice Address - Street 1:3005 S RIVERSIDE DR STE 103
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1500
Practice Address - Country:US
Practice Address - Phone:608-313-8600
Practice Address - Fax:608-312-2406
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5455-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant