Healthcare Provider Details

I. General information

NPI: 1598222879
Provider Name (Legal Business Name): KOLETTE A BUTLER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WILLIAMS FIELD RD STE 200
GILBERT AZ
85295-0764
US

IV. Provider business mailing address

4928 E ENCANTO ST
MESA AZ
85205-5322
US

V. Phone/Fax

Practice location:
  • Phone: 480-322-5720
  • Fax: 480-448-1582
Mailing address:
  • Phone: 480-322-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number004926
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number004926
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: