Healthcare Provider Details

I. General information

NPI: 1174031926
Provider Name (Legal Business Name): MICHAEL HUNTER BUTCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2018
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 HIBISCUS BLVD
MERRITT ISLAND FL
32952-5070
US

IV. Provider business mailing address

475 S JOHN RODES BLVD
MELBOURNE FL
32904-1093
US

V. Phone/Fax

Practice location:
  • Phone: 321-961-7831
  • Fax: 407-960-3009
Mailing address:
  • Phone: 321-241-1170
  • Fax: 321-241-1171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: