Healthcare Provider Details

I. General information

NPI: 1548635329
Provider Name (Legal Business Name): GWYNNE BUTTRILL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2015
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22735 VENTURA WAY
CALIFORNIA MD
20619-5108
US

IV. Provider business mailing address

22735 VENTURA WAY
CALIFORNIA MD
20619-5108
US

V. Phone/Fax

Practice location:
  • Phone: 240-925-6283
  • Fax:
Mailing address:
  • Phone: 240-925-6283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM05083
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: