=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407973142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R RANDOLPH BUTTS PSYD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 06/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8383 SEMINOLE BLVD SUITE C
-----------------------------------------------------
City | SEMINOLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33772-4392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-391-3893
-----------------------------------------------------
Fax | 866-582-0237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 86071
-----------------------------------------------------
City | MADEIRA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33738-6071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-391-3893
-----------------------------------------------------
Fax | 866-582-0237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT RANDOLPH BUTTS
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 727-391-3893
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY4732
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------