Healthcare Provider Details

I. General information

NPI: 1184758245
Provider Name (Legal Business Name): KATHLEEN ANNE BUTLER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 RIVERSIDE AVE SUITE 3
MEDFORD MA
02155-4600
US

IV. Provider business mailing address

282 SUTTON AVE
OXFORD MA
01540-1824
US

V. Phone/Fax

Practice location:
  • Phone: 781-396-6221
  • Fax: 781-395-7716
Mailing address:
  • Phone: 781-396-6221
  • Fax: 781-395-7716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1062
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: