Provider Demographics
NPI:1104013754
Name:BUTLER, LATUNDRA R
Entity Type:Individual
Prefix:MRS
First Name:LATUNDRA
Middle Name:R
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 1:1415 NE AMANDA JEAN WAY
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-7838
Mailing Address - Country:US
Mailing Address - Phone:816-820-6141
Mailing Address - Fax:
Practice Address - Street 1:14013 GARNETT ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66221-2807
Practice Address - Country:US
Practice Address - Phone:816-356-4615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO10063429320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities