Provider Demographics
NPI:1508462508
Name:BUTLER, AUDREY MICHELLE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:MICHELLE
Last Name:BUTLER
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 1:378 WENTWORTH CIR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7229
Mailing Address - Country:US
Mailing Address - Phone:770-313-6554
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3255
Practice Address - Country:US
Practice Address - Phone:770-812-3839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health