Healthcare Provider Details

I. General information

NPI: 1366099541
Provider Name (Legal Business Name): RICKEY BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W PENNSYLVANIA AVE STE 415
TOWSON MD
21204-5017
US

IV. Provider business mailing address

2206 BRANDERWOOD DR
GREENSBORO NC
27407-6072
US

V. Phone/Fax

Practice location:
  • Phone: 443-991-4117
  • Fax:
Mailing address:
  • Phone: 336-508-4884
  • Fax: 877-400-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: