Provider Demographics
NPI:1255000345
Name:BUTLER, KELLY L (LMBT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7315 CREEKWOOD QUORUM DR APT 205
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-7549
Mailing Address - Country:US
Mailing Address - Phone:704-606-6897
Mailing Address - Fax:
Practice Address - Street 1:2585 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-0418
Practice Address - Country:US
Practice Address - Phone:704-606-6897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14087225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist