Healthcare Provider Details

I. General information

NPI: 1942133376
Provider Name (Legal Business Name): MACKENZIE BUTLER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 CANAL ST STE 203
POOLER GA
31322-4104
US

IV. Provider business mailing address

5798 OGEECHEE RD APT 436
SAVANNAH GA
31405-9537
US

V. Phone/Fax

Practice location:
  • Phone: 912-988-1283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA005513
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: