Provider Demographics
NPI:1619261880
Name:BUTERA, JACQUELINE ANN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:BUTERA
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 1:100 SARATOGA VILLAGE BLVD SUITE 35
Mailing Address - Street 2:NEWMEADOW SARATOGA SCHOOL
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020
Mailing Address - Country:US
Mailing Address - Phone:518-899-9235
Mailing Address - Fax:
Practice Address - Street 1:100 SARATOGA VILLAGE BLVD
Practice Address - Street 2:SUITE 35
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-3737
Practice Address - Country:US
Practice Address - Phone:518-899-9235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2373797103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool