Provider Demographics
NPI:1629492715
Name:BUTGEREIT, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BUTGEREIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S BROADWAY
Mailing Address - Street 2:SUITE 18
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-857-8500
Mailing Address - Fax:701-857-8555
Practice Address - Street 1:1015 S BROADWAY
Practice Address - Street 2:SUITE 18
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-857-8500
Practice Address - Fax:701-857-8555
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND781-3-15-14-235101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional