Provider Demographics
NPI:1700432416
Name:BUTCHER, MARIANNE TAVORA
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:TAVORA
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13612 TONYA ANNE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-3001
Mailing Address - Country:US
Mailing Address - Phone:757-354-8975
Mailing Address - Fax:
Practice Address - Street 1:8451 US 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5450
Practice Address - Country:US
Practice Address - Phone:813-671-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28415225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant