Healthcare Provider Details

I. General information

NPI: 1790174829
Provider Name (Legal Business Name): TAHANAE BUTLER MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 ATLANTIC AVE STE 103
LONG BEACH CA
90807-3529
US

IV. Provider business mailing address

3939 ATLANTIC AVE STE 103
LONG BEACH CA
90807-3529
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-8480
  • Fax:
Mailing address:
  • Phone: 626-577-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: