MEDICARE: DR. SUSAN REIS BUTLER DOCTORATE

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	103TC1900X	Counseling Psychologist	PYO 1451	MO
2	103TF0000X	Family Psychologist	PYO 1451	MO
3	103TP2701X	Group Psychotherapy Psychologist	PYO1451	MO
4	103TP2701X	Group Psychotherapy Psychologist	PYO 1451	MO
5	103T00000X	Psychologist	PYO 1451	MO

General Provider Information

NPI Number	:	1487612941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN REIS BUTLER DOCTORATE

Provider Business Mailing Address
First Line	:	7654 RIVER WALK CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63129-5830
Country	:	US
Telephone Number	:	314-846-9616
Fax Number	:	314-846-3531

Provider Business Practice Location Address
First Line	:	12962 TESSON FERRY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2915
Country	:	US
Telephone Number	:	314-849-7177
Fax Number	:

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

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	09/11/2019

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