Healthcare Provider Details

I. General information

NPI: 1659236578
Provider Name (Legal Business Name): KEVIN BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 N 6TH ST
SPRINGFIELD IL
62702-5313
US

IV. Provider business mailing address

1827 E IRELAND RD
SOUTH BEND IN
46614-2845
US

V. Phone/Fax

Practice location:
  • Phone: 574-387-4313
  • Fax: 574-204-2868
Mailing address:
  • Phone: 765-628-7400
  • Fax: 574-204-2868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-501025
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: