Provider Demographics
NPI:1740721406
Name:TRAVELING PHYSICAL THERAPIST PLLC
Entity type:Organization
Organization Name:TRAVELING PHYSICAL THERAPIST PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:ORTHOTIST
Authorized Official - Phone:928-515-1748
Mailing Address - Street 1:353 CIMARRON CT
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1563
Mailing Address - Country:US
Mailing Address - Phone:928-515-4178
Mailing Address - Fax:928-233-6932
Practice Address - Street 1:520 W SHELDON ST
Practice Address - Street 2:STE 6
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2717
Practice Address - Country:US
Practice Address - Phone:928-515-1748
Practice Address - Fax:928-445-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZC51320335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZC51320OtherORTHOTIST