Provider Demographics
NPI:1154713295
Name:DONAVANT-BUTLER, THERESA (LMT9185)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:DONAVANT-BUTLER
Suffix:
Gender:F
Credentials:LMT9185
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1112
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-1112
Mailing Address - Country:US
Mailing Address - Phone:503-250-0127
Mailing Address - Fax:
Practice Address - Street 1:564 GLATT CIRCLE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071
Practice Address - Country:US
Practice Address - Phone:503-250-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist