Healthcare Provider Details

I. General information

NPI: 1508030578
Provider Name (Legal Business Name): RONNIE BUTLER, LPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2008
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 N PORTLAND AVE STE 100
OKLAHOMA CITY OK
73112-6171
US

IV. Provider business mailing address

4911 N PORTLAND AVE STE 100
OKLAHOMA CITY OK
73112-6171
US

V. Phone/Fax

Practice location:
  • Phone: 405-501-0721
  • Fax:
Mailing address:
  • Phone: 405-501-0721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3975
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number3975
License Number StateOK

VIII. Authorized Official

Name: RONNIE BUTLER
Title or Position: PSYCHOTHERAPIST
Credential: LPC
Phone: 405-501-0721