Provider Demographics
NPI:1861099780
Name:BUTLER, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 RICH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-4937
Mailing Address - Country:US
Mailing Address - Phone:330-447-5149
Mailing Address - Fax:
Practice Address - Street 1:4506 HONEYMOON DR
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-1128
Practice Address - Country:US
Practice Address - Phone:330-896-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7610393376J00000X
OHLPN.127636.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty