Provider Demographics
NPI:1255977062
Name:BUTLER, AUSTIN THOMAS (ATC)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:THOMAS
Last Name:BUTLER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3631
Mailing Address - Country:US
Mailing Address - Phone:618-942-2171
Mailing Address - Fax:
Practice Address - Street 1:201 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3631
Practice Address - Country:US
Practice Address - Phone:618-942-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960046602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer