Provider Demographics
NPI:1467961474
Name:BUTLER, KATELYN MARIE (BCBA)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 BLACKBERRY RUN TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-2129
Mailing Address - Country:US
Mailing Address - Phone:404-290-3422
Mailing Address - Fax:678-303-0347
Practice Address - Street 1:727 BLACKBERRY RUN TRL
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-2129
Practice Address - Country:US
Practice Address - Phone:404-290-3422
Practice Address - Fax:678-303-0347
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-17-27406103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003205692DMedicaid