Provider Demographics
NPI:1265451462
Name:BUTTS, ROBERT RANDOLPH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RANDOLPH
Last Name:BUTTS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 54TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-1703
Mailing Address - Country:US
Mailing Address - Phone:727-548-6100
Mailing Address - Fax:727-545-0960
Practice Address - Street 1:6333 54TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-1703
Practice Address - Country:US
Practice Address - Phone:727-548-6100
Practice Address - Fax:727-545-0960
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0004732103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73942TMedicare PIN