Provider Demographics
NPI:1962761205
Name:BUTLER, MIKKI LEE (MPT)
Entity type:Individual
Prefix:
First Name:MIKKI
Middle Name:LEE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 LAWNWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-0922
Mailing Address - Country:US
Mailing Address - Phone:530-680-7232
Mailing Address - Fax:
Practice Address - Street 1:3650 LAWNWOOD CT
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-0922
Practice Address - Country:US
Practice Address - Phone:530-680-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38966225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist