Provider Demographics
NPI:1417014069
Name:BUTLER, DAVID LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 NE MIAMI GARDENS DR
Mailing Address - Street 2:#316
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-5035
Mailing Address - Country:US
Mailing Address - Phone:704-640-3264
Mailing Address - Fax:
Practice Address - Street 1:1835 NE MIAMI GARDENS DR
Practice Address - Street 2:#316
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-5035
Practice Address - Country:US
Practice Address - Phone:704-640-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2008-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4064103G00000X, 103T00000X, 103TB0200X, 103TC0700X, 103TF0200X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73387Medicare ID - Type Unspecified