Provider Demographics
NPI:1518142041
Name:BUTEAU, ANDRE PAUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:PAUL
Last Name:BUTEAU
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:PO BOX 127B
Mailing Address - Street 2:
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-1032
Mailing Address - Country:US
Mailing Address - Phone:601-664-6195
Mailing Address - Fax:601-359-6945
Practice Address - Street 1:HIGHWAY 475 SOUTH
Practice Address - Street 2:HUDSPETH REGIONAL CENTER
Practice Address - City:WHITFIELD
Practice Address - State:MS
Practice Address - Zip Code:39193-1032
Practice Address - Country:US
Practice Address - Phone:601-664-6195
Practice Address - Fax:601-359-6945
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33521103T00000X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126594Medicaid