Provider Demographics
NPI:1477945277
Name:BUTCHER, VELMA
Entity Type:Individual
Prefix:
First Name:VELMA
Middle Name:
Last Name:BUTCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 N 55TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-1425
Mailing Address - Country:US
Mailing Address - Phone:813-381-9726
Mailing Address - Fax:813-412-4396
Practice Address - Street 1:3703 N 55TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-1425
Practice Address - Country:US
Practice Address - Phone:813-381-9726
Practice Address - Fax:813-412-4396
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906543320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010976200Medicaid