Provider Demographics
NPI:1639158868
Name:BUTRYN, MATT F (PHD)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:F
Last Name:BUTRYN
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 1:1 HUNTINGTON RD
Mailing Address - Street 2:SUITE 802
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7204
Mailing Address - Country:US
Mailing Address - Phone:706-548-0018
Mailing Address - Fax:706-548-2389
Practice Address - Street 1:1 HUNTINGTON RD
Practice Address - Street 2:SUITE 802
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7204
Practice Address - Country:US
Practice Address - Phone:706-548-0018
Practice Address - Fax:706-548-2389
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2503103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00918222AMedicaid
GAP36956Medicare ID - Type Unspecified