MEDICARE: LAILAH BUTLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	IMH21509	FL

General Provider Information

NPI Number	:	1417699836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAILAH BUTLER

Provider Business Mailing Address
First Line	:	1003 S ALEXANDER ST STE 3
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-8400
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1003 S ALEXANDER ST STE 3
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-8400
Country	:	US
Telephone Number	:	813-730-1010
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2022
Last Update Date	:	04/07/2022

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