Provider Demographics
NPI:1679881213
Name:BUTLER, BRYAN J (LMP)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7492
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-7492
Mailing Address - Country:US
Mailing Address - Phone:360-359-0767
Mailing Address - Fax:
Practice Address - Street 1:306 10TH AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1340
Practice Address - Country:US
Practice Address - Phone:360-359-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60070300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist