Healthcare Provider Details

I. General information

NPI: 1770780595
Provider Name (Legal Business Name): SHANTELLE NOEL BUETHE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 ALPHA RD
TURLOCK CA
95380-5505
US

IV. Provider business mailing address

743 ALPHA RD
TURLOCK CA
95380-5505
US

V. Phone/Fax

Practice location:
  • Phone: 209-668-4651
  • Fax: 209-668-4666
Mailing address:
  • Phone: 209-668-4651
  • Fax: 209-668-4666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF#52721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: