Provider Demographics
NPI:1447302765
Name:BUTLER, BERENDA (MPT)
Entity type:Individual
Prefix:
First Name:BERENDA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 GREEN VALLEY CIR APT 315
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-8019
Mailing Address - Country:US
Mailing Address - Phone:310-645-3758
Mailing Address - Fax:
Practice Address - Street 1:112 HARVARD AVE # 260
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4716
Practice Address - Country:US
Practice Address - Phone:909-981-7251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT20480BMedicare ID - Type Unspecified