=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366255432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICGRA PSYCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2025
-----------------------------------------------------
Last Update Date | 07/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2375 E CAMELBACK RD STE 600
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-3493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-905-3600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 ANDOVER PARK W STE 200
-----------------------------------------------------
City | TUKWILA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98188-3379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-905-3600
-----------------------------------------------------
Fax | 206-485-4710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIC NURSE PRACTITIONER
-----------------------------------------------------
Name | ODETTE AMANDA E BUTLER
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 206-905-3600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------