Healthcare Provider Details

I. General information

NPI: 1609138981
Provider Name (Legal Business Name): LYNDI BUTLER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 N WILLIAMSBURG DR
BLOOMINGTON IL
61704-3528
US

IV. Provider business mailing address

135 N WILLIAMSBURG DR
BLOOMINGTON IL
61704-3528
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-9104
  • Fax:
Mailing address:
  • Phone: 309-661-8823
  • Fax: 309-661-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160005697
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: