Healthcare Provider Details

I. General information

NPI: 1053240705
Provider Name (Legal Business Name): DESTINAE BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6240 OLD DOBBIN LN STE 100
COLUMBIA MD
21045-5956
US

IV. Provider business mailing address

6240 OLD DOBBIN LN STE 100
COLUMBIA MD
21045-5956
US

V. Phone/Fax

Practice location:
  • Phone: 443-539-7326
  • Fax:
Mailing address:
  • Phone: 855-782-7822
  • Fax: 855-782-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: