Provider Demographics
NPI:1255894838
Name:BUTSCHER, MARY ANN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BUTSCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2740
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:11276 5TH ST STE 400
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0923
Practice Address - Country:US
Practice Address - Phone:909-481-0437
Practice Address - Fax:909-481-0837
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28529OtherPT LICENSE