Basic Information
| Provider Information | |||||||||
| NPI: | 1790882058 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 310 HOLDERFORD RD | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377635412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657170115 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 CAVETTE HILL LN | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379346673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657774000 | ||||||||
| FaxNumber: | 8657771470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 0000003523 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.