Healthcare Provider Details

I. General information

NPI: 1164124905
Provider Name (Legal Business Name): MIKAYLA RENEE BUTCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2023
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT ST LUCIE FL
34952-5530
US

IV. Provider business mailing address

2265 STARLIGHT CT APT 280
MELBOURNE FL
32904-8130
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-0444
  • Fax: 772-219-1339
Mailing address:
  • Phone: 321-615-5549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-271966
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: