Provider Demographics
NPI:1407973142
Name:R RANDOLPH BUTTS PSYD PA
Entity Type:Organization
Organization Name:R RANDOLPH BUTTS PSYD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:RANDOLPH
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:727-391-3893
Mailing Address - Street 1:PO BOX 86071
Mailing Address - Street 2:
Mailing Address - City:MADEIRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33738-6071
Mailing Address - Country:US
Mailing Address - Phone:727-391-3893
Mailing Address - Fax:866-582-0237
Practice Address - Street 1:8383 SEMINOLE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4392
Practice Address - Country:US
Practice Address - Phone:727-391-3893
Practice Address - Fax:866-582-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4732103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAF039Medicare PIN