Basic Information
| Provider Information | |||||||||
| NPI: | 1326594243 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTKOVICH | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JACOB | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 MEDICAL DRIVE | ||||||||
| Address2: | LIFESPAN THERAPY | ||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129886666 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7120 CORBIN AVE | ||||||||
| Address2: | |||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913353618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188814540 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2016 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06005233A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225200000X | 48919 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.