Healthcare Provider Details

I. General information

NPI: 1023774114
Provider Name (Legal Business Name): KENNETH MICHAEL BUTLER SAC-IT, NREMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 N PROSPECT AVE
MILWAUKEE WI
53202-6720
US

IV. Provider business mailing address

1681 N PROSPECT AVE
MILWAUKEE WI
53202-6720
US

V. Phone/Fax

Practice location:
  • Phone: 414-273-8484
  • Fax:
Mailing address:
  • Phone: 414-273-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19378-130
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberR1032909
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: