Provider Demographics
NPI:1144695248
Name:BUTLER, ERICA DANIELLE (COTA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:DANIELLE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 BLACK TERN LN
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-5845
Mailing Address - Country:US
Mailing Address - Phone:580-212-2733
Mailing Address - Fax:
Practice Address - Street 1:1029 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4862
Practice Address - Country:US
Practice Address - Phone:918-423-2220
Practice Address - Fax:918-423-2620
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1598224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant