Provider Demographics
NPI:1629890595
Name:BUTLER, KENNETH D JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:BUTLER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8071 GREEN ORCHARD RD APT 11
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-6511
Mailing Address - Country:US
Mailing Address - Phone:443-960-9594
Mailing Address - Fax:
Practice Address - Street 1:8071 GREEN ORCHARD RD APT 11
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6511
Practice Address - Country:US
Practice Address - Phone:443-960-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-342756106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician