Provider Demographics
NPI:1770797524
Name:BUTKUS, NICOLE (RPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BUTKUS
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:POLEC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:345 BUCKLAND HILLS DR APT 11132
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-8736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 WOLCOTT RD
Practice Address - Street 2:ADVANCED PHYSICAL THERAPY
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2613
Practice Address - Country:US
Practice Address - Phone:203-879-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8074OtherLICENSE#