Provider Demographics
NPI:1083049852
Name:BUTLER, NICOLE BLAIR (M ED)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:BLAIR
Last Name:BUTLER
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:BLAIR
Other - Last Name:GAYNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:914 SHERMER RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-3729
Mailing Address - Country:US
Mailing Address - Phone:773-456-8779
Mailing Address - Fax:847-715-9270
Practice Address - Street 1:914 SHERMER RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-3729
Practice Address - Country:US
Practice Address - Phone:773-456-8779
Practice Address - Fax:847-715-9270
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist