Healthcare Provider Details

I. General information

NPI: 1962592675
Provider Name (Legal Business Name): MS. KIMBERLY BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WESTCHESTER SQ # 62
BRONX NY
10461-3525
US

IV. Provider business mailing address

631 E 168TH ST APT 3A
BRONX NY
10456-3879
US

V. Phone/Fax

Practice location:
  • Phone: 718-931-4045
  • Fax:
Mailing address:
  • Phone: 718-931-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberN/A
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: