Provider Demographics
NPI:1184218224
Name:BUTLER, TRACI RAE
Entity Type:Individual
Prefix:MISS
First Name:TRACI
Middle Name:RAE
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 1:2713 DEERFIELD CRES
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2447
Mailing Address - Country:US
Mailing Address - Phone:757-653-6185
Mailing Address - Fax:757-956-6100
Practice Address - Street 1:105 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1701
Practice Address - Country:US
Practice Address - Phone:757-956-6100
Practice Address - Fax:757-956-6101
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst