Healthcare Provider Details

I. General information

NPI: 1700700275
Provider Name (Legal Business Name): MARISSA ASHLEY BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 COLUMBIA RD STE 101
AUGUSTA GA
30907-1482
US

IV. Provider business mailing address

4106 COLUMBIA RD STE 101
AUGUSTA GA
30907-1482
US

V. Phone/Fax

Practice location:
  • Phone: 706-426-0583
  • Fax:
Mailing address:
  • Phone: 706-426-0583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S00000X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: