Provider Demographics
NPI:1518591734
Name:BUTLER, BRECK
Entity Type:Individual
Prefix:
First Name:BRECK
Middle Name:
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 1:1851 NW CIVIC DR
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5566
Mailing Address - Country:US
Mailing Address - Phone:971-292-1050
Mailing Address - Fax:
Practice Address - Street 1:1851 NW CIVIC DR
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5566
Practice Address - Country:US
Practice Address - Phone:971-292-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRBT-20-113268OtherRBT
ORIN-10206298OtherOR BARB RBAI