Provider Demographics
NPI:1184637779
Name:KERN-BUTLER, TIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TIA
Middle Name:
Last Name:KERN-BUTLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12360 66TH ST STE 930
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-3434
Mailing Address - Country:US
Mailing Address - Phone:727-417-2812
Mailing Address - Fax:727-499-6882
Practice Address - Street 1:12360 66TH ST STE 930
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-3434
Practice Address - Country:US
Practice Address - Phone:727-417-2812
Practice Address - Fax:727-499-6882
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6186103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCW378AOtherMEDICARE PTAN
FL070618300Medicaid