MEDICARE: KATHERINE ELLEN BUTLER AMFT

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	IMF82150	CA

General Provider Information

NPI Number	:	1689160012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE ELLEN BUTLER AMFT

Provider Business Mailing Address
First Line	:	689 FOREST WAY
Second Line	:
City	:	MILL VALLEY
State	:	CA
Zip	:	94941-3974
Country	:	US
Telephone Number	:	415-578-8367
Fax Number	:

Provider Business Practice Location Address
First Line	:	3434 MENDOCINO AVE # A
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-2274
Country	:	US
Telephone Number	:	707-284-1978
Fax Number	:

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

Provider Enumeration Date	:	07/09/2018
Last Update Date	:	07/09/2018

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