Provider Demographics
NPI:1588078653
Name:BUTTRAM, LAURA (PTA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BUTTRAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13101 HARTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-1511
Mailing Address - Country:US
Mailing Address - Phone:858-259-2222
Mailing Address - Fax:
Practice Address - Street 1:13101 HARTFIELD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-1511
Practice Address - Country:US
Practice Address - Phone:858-259-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9539314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility