Provider Demographics
NPI:1982139648
Name:BUTLER, ANN MARIE SOUTHEY (LMT)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE SOUTHEY
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:MULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2311 E. BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-208-8843
Mailing Address - Fax:971-319-2195
Practice Address - Street 1:2311 E. BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-208-8843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09411225200000X
OR17700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant