Healthcare Provider Details

I. General information

NPI: 1326746736
Provider Name (Legal Business Name): TUCKER MCKENZIE WILLIAM BUTLER PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 04/15/2025
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD DEPT PSYCHIATRY, STE 141A
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-1700
  • Fax: 314-627-7225
Mailing address:
  • Phone: 314-286-1700
  • Fax: 314-627-7225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023006145
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: