Healthcare Provider Details

I. General information

NPI: 1700432416
Provider Name (Legal Business Name): MARIANNE TAVORA BUTCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2019
Last Update Date: 08/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 US 301 S
RIVERVIEW FL
33578-5450
US

IV. Provider business mailing address

13612 TONYA ANNE DR
RIVERVIEW FL
33579-3001
US

V. Phone/Fax

Practice location:
  • Phone: 813-671-0222
  • Fax:
Mailing address:
  • Phone: 757-354-8975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA28415
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: