Healthcare Provider Details

I. General information

NPI: 1790263945
Provider Name (Legal Business Name): THULISILE BUTHELEZI M.S., BCBA, LBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GREAT VALLEY PKWY STE 270
MALVERN PA
19355-1426
US

IV. Provider business mailing address

5 GREAT VALLEY PKWY STE 270
MALVERN PA
19355-1426
US

V. Phone/Fax

Practice location:
  • Phone: 484-757-5538
  • Fax: 610-889-9726
Mailing address:
  • Phone: 484-757-5538
  • Fax: 610-889-9726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-44472
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-57925
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: