Healthcare Provider Details

I. General information

NPI: 1548838816
Provider Name (Legal Business Name): LAURA NICOLE BUTLER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date: 04/03/2023
Reactivation Date: 04/18/2023

III. Provider practice location address

1438 S. GRAND BLVD.
ST. LOUIS MO
63104
US

IV. Provider business mailing address

1438 S. GRAND BLVD.
ST. LOUIS MO
63104
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4850
  • Fax: 314-977-5155
Mailing address:
  • Phone: 314-977-4850
  • Fax: 314-977-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2025-01279
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: