Healthcare Provider Details

I. General information

NPI: 1043306723
Provider Name (Legal Business Name): GRANT JACKSON BUTTERBAUGH JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 PRYTANIA ST SUITE 309
NEW ORLEANS LA
70115-3500
US

IV. Provider business mailing address

3525 PRYTANIA ST SUITE 309
NEW ORLEANS LA
70115-3500
US

V. Phone/Fax

Practice location:
  • Phone: 504-309-9855
  • Fax: 504-814-4346
Mailing address:
  • Phone: 504-309-9855
  • Fax: 504-814-4346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number681
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number681
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: