Healthcare Provider Details

I. General information

NPI: 1851863674
Provider Name (Legal Business Name): MYISHA BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 FAIRMOUNT AVE
SAN DIEGO CA
92105-3422
US

IV. Provider business mailing address

3660 FAIRMOUNT AVE
SAN DIEGO CA
92105-3422
US

V. Phone/Fax

Practice location:
  • Phone: 619-980-5213
  • Fax:
Mailing address:
  • Phone: 619-980-5213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: